Provider Demographics
NPI:1407816549
Name:HARRIS, CYNTHIA JORDAN (OD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:JORDAN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CYNTHIA
Other - Middle Name:JORDAN
Other - Last Name:MCMURRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 3211
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-3211
Mailing Address - Country:US
Mailing Address - Phone:229-244-3000
Mailing Address - Fax:229-244-1934
Practice Address - Street 1:2108 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2947
Practice Address - Country:US
Practice Address - Phone:229-244-3000
Practice Address - Fax:229-244-1934
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001699152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00802293AMedicaid
GAU71982Medicare UPIN
GA41ZCDKBMedicare ID - Type UnspecifiedMEDICARE