Healthcare Provider Details

I. General information

NPI: 1053739821
Provider Name (Legal Business Name): JONATHAN HARRISON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5169 S COTTONWOOD ST STE 520
MURRAY UT
84107-6756
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3500
  • Fax: 801-507-3505
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number14140972-4201
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number10705078-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: