Provider Demographics
NPI:1831388982
Name:HARRISON, FAWN G (MD)
Entity type:Individual
Prefix:
First Name:FAWN
Middle Name:G
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FAWN
Other - Middle Name:A
Other - Last Name:GRIGSBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2177
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34265-2177
Mailing Address - Country:US
Mailing Address - Phone:863-494-8436
Mailing Address - Fax:863-491-4328
Practice Address - Street 1:900 N ROBERT AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-8712
Practice Address - Country:US
Practice Address - Phone:863-494-8436
Practice Address - Fax:863-491-4328
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN8799390200000X
FLME102181208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000012400Medicaid
FL50761OtherBCBS