Provider Demographics
NPI:1043274947
Name:BARRY, TIMOTHY JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:BARRY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 GERSTNER MEMORIAL BLVD # 14
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-3231
Mailing Address - Country:US
Mailing Address - Phone:337-475-9500
Mailing Address - Fax:
Practice Address - Street 1:3601 GERSTNER MEMORIAL BLVD # 14
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-3231
Practice Address - Country:US
Practice Address - Phone:337-475-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04948T152W00000X
LA1192-344T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1998273Medicaid
LA1998273Medicaid