Provider Demographics
NPI:1730147307
Name:HARLAN, CARL D JR (DO)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:D
Last Name:HARLAN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:231-547-4024
Mailing Address - Fax:734-677-7407
Practice Address - Street 1:14700 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720
Practice Address - Country:US
Practice Address - Phone:231-547-4024
Practice Address - Fax:734-677-7407
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010085932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI300086775OtherMEDICARE RR PIN
MI0982318OtherHEALTHPOLUS
MI3450062Medicaid
MI3151500034OtherBCBS INDIVIDUAL ID
MI300086775OtherRR MEDICARE
MI310A510270OtherBCBS
E37558Medicare UPIN
MI0982318OtherHEALTHPOLUS
MI310A510270OtherBCBS