Provider Demographics
NPI:1194715078
Name:HARLEY, GARTH HOWLAND JR (MD)
Entity type:Individual
Prefix:
First Name:GARTH
Middle Name:HOWLAND
Last Name:HARLEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 NORTHSTAR WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9262
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-524-4240
Practice Address - Street 1:1530 BESSIE AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3080
Practice Address - Country:US
Practice Address - Phone:209-342-2300
Practice Address - Fax:209-524-4240
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG689922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G689920OtherBLUE SHIELD
CA00G689920Medicaid
CA00G689927Medicare PIN
CA00G689920OtherBLUE SHIELD
CA00G689921Medicare PIN
CA00G689920Medicaid
CA00G689926Medicare PIN
CA00G689922Medicare PIN
CA00G689923Medicare PIN