Provider Demographics
NPI:1215058961
Name:HARRIS, JEFFREY ALAN (LDO)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:ALAN
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N BASIL ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:OH
Mailing Address - Zip Code:43105-1004
Mailing Address - Country:US
Mailing Address - Phone:740-862-8381
Mailing Address - Fax:
Practice Address - Street 1:220 N BASIL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:OH
Practice Address - Zip Code:43105-1004
Practice Address - Country:US
Practice Address - Phone:740-862-8381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH967S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0603421Medicaid