Provider Demographics
NPI:1073664587
Name:HARRIS, TIMOTHY R (OD PLC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:R
Last Name:HARRIS
Suffix:
Gender:M
Credentials:OD PLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 S STATE RD
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1904
Mailing Address - Country:US
Mailing Address - Phone:810-653-3206
Mailing Address - Fax:
Practice Address - Street 1:1016 S STATE RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1904
Practice Address - Country:US
Practice Address - Phone:810-653-3206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITH4901003573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U33211Medicare UPIN
MI4918860001Medicare NSC