Provider Demographics
NPI:1962500280
Name:HARRIS, MARK WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
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 1:137 PASTURE DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-4961
Mailing Address - Country:US
Mailing Address - Phone:603-623-9834
Mailing Address - Fax:
Practice Address - Street 1:1875 S WILLOW ST
Practice Address - Street 2:MERRIMACK VISION CARE
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-2363
Practice Address - Country:US
Practice Address - Phone:603-644-6100
Practice Address - Fax:603-314-0404
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNH616152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30350210Medicaid
NHU76750Medicare UPIN
NHRE5449Medicare ID - Type Unspecified