Provider Demographics
NPI:1972791218
Name:HARRISON, THEODORE JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:
Last Name:HARRISON
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 SILVER CHARM CIR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3343
Mailing Address - Country:US
Mailing Address - Phone:757-375-5017
Mailing Address - Fax:
Practice Address - Street 1:3020 SILVER CHARM CIR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3343
Practice Address - Country:US
Practice Address - Phone:757-375-5017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman