Healthcare Provider Details

I. General information

NPI: 1730151127
Provider Name (Legal Business Name): FREDERICK R HARRIS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 HUNTINGTON DR SUITE F
SOUTH PASADENA CA
91030-4967
US

IV. Provider business mailing address

1941 HUNTINGTON DR SUITE F
SOUTH PASADENA CA
91030-4967
US

V. Phone/Fax

Practice location:
  • Phone: 626-799-2212
  • Fax: 626-799-4491
Mailing address:
  • Phone: 626-799-2212
  • Fax: 626-799-4491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT4835T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: