Healthcare Provider Details

I. General information

NPI: 1649252388
Provider Name (Legal Business Name): JOHN W HARLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MARILYN AVE SUITE 4
GOSHEN IN
46526-4800
US

IV. Provider business mailing address

101 MARILYN AVE SUITE 4
GOSHEN IN
46526-4800
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-2769
  • Fax: 574-534-6822
Mailing address:
  • Phone: 574-533-2769
  • Fax: 574-534-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number31690
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number31690
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: