Provider Demographics
NPI:1629046818
Name:HARRIS, JEFFREY DONALD (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DONALD
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 1:9975SWFREWING ST 130
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5091
Mailing Address - Country:US
Mailing Address - Phone:503-906-3596
Mailing Address - Fax:503-906-1014
Practice Address - Street 1:11020 SW BEAVERTON HILLSDALE HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3007
Practice Address - Country:US
Practice Address - Phone:503-526-9697
Practice Address - Fax:503-644-8330
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11820152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU91703Medicare UPIN