Provider Demographics
NPI:1891913414
Name:TIMOTHY R HARRIS OD PLC
Entity Type:Organization
Organization Name:TIMOTHY R HARRIS OD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:810-653-3206
Mailing Address - Street 1:1016 S STATE RD
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1904
Mailing Address - Country:US
Mailing Address - Phone:810-653-3206
Mailing Address - Fax:810-653-9779
Practice Address - Street 1:1016 S STATE RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1904
Practice Address - Country:US
Practice Address - Phone:810-653-3206
Practice Address - Fax:810-653-9779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITH4901003573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4918860001OtherDURABLE MEDCAL EQUIPMENT REGIONAL CARRIER
MIU33211Medicare UPIN