Healthcare Provider Details

I. General information

NPI: 1689765786
Provider Name (Legal Business Name): PAUL ALAN HARRIS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 MADISON AVE
MEMPHIS TN
38104-2211
US

IV. Provider business mailing address

1245 MADISON AVE
MEMPHIS TN
38104-2211
US

V. Phone/Fax

Practice location:
  • Phone: 443-857-3925
  • Fax: 410-252-1719
Mailing address:
  • Phone: 901-722-3250
  • Fax: 901-722-3347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberTA0816
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2951
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: