Healthcare Provider Details

I. General information

NPI: 1649272493
Provider Name (Legal Business Name): JOHN DERRICK HARNESS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 WOODSON RD SUITE 202
OVERLAND MO
63114-5606
US

IV. Provider business mailing address

2040 WOODSON RD SUITE 202
OVERLAND MO
63114-5606
US

V. Phone/Fax

Practice location:
  • Phone: 314-473-1296
  • Fax: 314-558-7575
Mailing address:
  • Phone: 314-473-1296
  • Fax: 314-558-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2004024287
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: