Healthcare Provider Details

I. General information

NPI: 1285869834
Provider Name (Legal Business Name): TIMOTHY C HARRIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 GRAHAM ROAD WEST
ITHACA NY
14850
US

IV. Provider business mailing address

10 GRAHAM ROAD WEST
ITHACA NY
14850
US

V. Phone/Fax

Practice location:
  • Phone: 607-257-2188
  • Fax: 607-266-7341
Mailing address:
  • Phone: 607-257-2188
  • Fax: 607-266-7341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number266726
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: