Provider Demographics
NPI:1093775785
Name:HARRIS, TIMOTHY PAUL (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:PAUL
Last Name:HARRIS
Suffix:
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 1:1201 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-2504
Mailing Address - Country:US
Mailing Address - Phone:620-343-6800
Mailing Address - Fax:620-341-7821
Practice Address - Street 1:1301 W 12TH AVE STE 301
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-2590
Practice Address - Country:US
Practice Address - Phone:620-343-2376
Practice Address - Fax:620-342-0087
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0521008208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
020015054OtherRAILROAD MEDICARE
KS100231930AMedicaid
KS100231930AMedicaid
KS101440Medicare ID - Type Unspecified
020015054Medicare PIN