Provider Demographics
NPI:1437200516
Name:HARRIS, BERRY ALLEN (OD)
Entity Type:Individual
Prefix:
First Name:BERRY
Middle Name:ALLEN
Last Name:HARRIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5184 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47805-1639
Mailing Address - Country:US
Mailing Address - Phone:812-466-9130
Mailing Address - Fax:217-446-5554
Practice Address - Street 1:2807 N VERMILION ST STE 4
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-1444
Practice Address - Country:US
Practice Address - Phone:217-446-5554
Practice Address - Fax:217-446-5554
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-8471152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN150550Medicare ID - Type Unspecified
INU80295Medicare UPIN