Provider Demographics
NPI:1245223361
Name:HARRIS, JACK A (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 BIG A ROAD
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-6002
Mailing Address - Country:US
Mailing Address - Phone:706-886-0421
Mailing Address - Fax:706-297-7617
Practice Address - Street 1:274 BIG A ROAD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-6002
Practice Address - Country:US
Practice Address - Phone:706-886-0421
Practice Address - Fax:706-297-7617
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA29879207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA335410959AMedicaid
GAC24797Medicare UPIN