Provider Demographics
NPI:1275598526
Name:HARRIS, CLARENCE M (MD)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:M
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 1:2023 PROFESSIONAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073
Mailing Address - Country:US
Mailing Address - Phone:904-272-2020
Mailing Address - Fax:904-276-4386
Practice Address - Street 1:2023 PROFESSIONAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-272-2020
Practice Address - Fax:904-276-4386
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0015120207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4047763OtherAETNA
FL10075OtherBCBS
FL1635739001OtherCIGNA
FLCB1273OtherRAILROAD MEDICARE
FL1635739001OtherCIGNA
FL10075XMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER