Provider Demographics
NPI:1689765786
Name:HARRIS, PAUL ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ALAN
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 1:1245 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2211
Mailing Address - Country:US
Mailing Address - Phone:901-722-3250
Mailing Address - Fax:901-722-3347
Practice Address - Street 1:1245 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2211
Practice Address - Country:US
Practice Address - Phone:443-857-3925
Practice Address - Fax:410-252-1719
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0816152WV0400X
TN2951152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD399433-02OtherBCBS OF MD
MDT59945Medicare UPIN
MD399433-02OtherBCBS OF MD