Provider Demographics
NPI:1649272493
Name:HARNESS, JOHN DERRICK (DPM)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DERRICK
Last Name:HARNESS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:2040 WOODSON RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OVERLAND
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5606
Mailing Address - Country:US
Mailing Address - Phone:314-473-1296
Mailing Address - Fax:314-558-7575
Practice Address - Street 1:2040 WOODSON RD
Practice Address - Street 2:SUITE 202
Practice Address - City:OVERLAND
Practice Address - State:MO
Practice Address - Zip Code:63114-5606
Practice Address - Country:US
Practice Address - Phone:314-473-1296
Practice Address - Fax:314-558-7575
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2004024287213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOV05560Medicare UPIN