MEDICARE: DR. JOHN DERRICK HARNESS D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	2004024287	MO

General Provider Information

NPI Number	:	1649272493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN DERRICK HARNESS D.P.M.

Provider Business Mailing Address
First Line	:	2040 WOODSON RD
Second Line	:	SUITE 202
City	:	OVERLAND
State	:	MO
Zip	:	63114-5606
Country	:	US
Telephone Number	:	314-473-1296
Fax Number	:	314-558-7575

Provider Business Practice Location Address
First Line	:	2040 WOODSON RD
Second Line	:	SUITE 202
City	:	OVERLAND
State	:	MO
Zip	:	63114-5606
Country	:	US
Telephone Number	:	314-473-1296
Fax Number	:	314-558-7575

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	04/01/2015

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