Provider Demographics
NPI:1407837776
Name:FARRIS, JACK C (OD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:C
Last Name:FARRIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:11601 SUN CIRCLE WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-4375
Mailing Address - Country:US
Mailing Address - Phone:443-367-0287
Mailing Address - Fax:301-677-8077
Practice Address - Street 1:KIMBROUGH AMBULATORY CARE CENTER
Practice Address - Street 2:ATTN: OPTOMETRY
Practice Address - City:FORT MEADE
Practice Address - State:MD
Practice Address - Zip Code:21044-5800
Practice Address - Country:US
Practice Address - Phone:301-677-8378
Practice Address - Fax:301-677-8077
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist