Healthcare Provider Details

I. General information

NPI: 1588653752
Provider Name (Legal Business Name): RONALD C HARRISON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 MIDWAY DR
SANTA ROSA CA
95405-5017
US

IV. Provider business mailing address

2320 MIDWAY DR
SANTA ROSA CA
95405-5017
US

V. Phone/Fax

Practice location:
  • Phone: 707-526-2020
  • Fax: 707-526-2032
Mailing address:
  • Phone: 707-526-2020
  • Fax: 707-526-2032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2000145741
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2555T
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT 6943 TPA
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: