1528112091 NPI number — WILLIAM BAXTER HARRIS OD OPTOMETRIST

Table of content: WILLIAM BAXTER HARRIS OD OPTOMETRIST (NPI 1528112091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528112091 NPI number — WILLIAM BAXTER HARRIS OD OPTOMETRIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
WILLIAM
Provider Middle Name:
BAXTER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD OPTOMETRIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528112091
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5964 MARINE AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
29 PALMS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92277-2330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-367-7607
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57990 29 PALMS HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 2B
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284-5878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-365-6868
Provider Business Practice Location Address Fax Number:
760-365-7632
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4923T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4923T . This is a "STATE OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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