Provider Demographics
NPI:1073004602
Name:HARRISON, JULIA DANIELLE (OD)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:DANIELLE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 PINEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3035
Mailing Address - Country:US
Mailing Address - Phone:229-382-4765
Mailing Address - Fax:229-382-4819
Practice Address - Street 1:2012 PINEVIEW AVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794
Practice Address - Country:US
Practice Address - Phone:229-382-4765
Practice Address - Fax:229-382-4819
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GAOPT003116152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOPT003116OtherSTATE LICENSE