Healthcare Provider Details

I. General information

NPI: 1225188709
Provider Name (Legal Business Name): JEFFREY NATHAN HARRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9612
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101244995
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number15346
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number15346
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: