Provider Demographics
NPI:1629296314
Name:HARRIS, FRED D (OD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:D
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 1:750 LIDO BLVD
Mailing Address - Street 2:APT 6B
Mailing Address - City:LIDO BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561
Mailing Address - Country:US
Mailing Address - Phone:917-952-7236
Mailing Address - Fax:
Practice Address - Street 1:151 MONTAGUE ST
Practice Address - Street 2:
Practice Address - City:BKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3504
Practice Address - Country:US
Practice Address - Phone:718-875-4609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY3157152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT86733Medicare UPIN