Provider Demographics
NPI:1720065253
Name:HARRISON, DOUGLAS G (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:G
Last Name:HARRISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2660
Mailing Address - Street 2:
Mailing Address - City:THATCHER
Mailing Address - State:AZ
Mailing Address - Zip Code:85552-2660
Mailing Address - Country:US
Mailing Address - Phone:928-424-4444
Mailing Address - Fax:928-424-4446
Practice Address - Street 1:2020 W 16TH ST
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4026
Practice Address - Country:US
Practice Address - Phone:928-424-4444
Practice Address - Fax:928-424-4446
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2012-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053918207V00000X
AZ41204207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVI23363Medicare UPIN