Provider Demographics
NPI:1649446055
Name:HARBUCK, TIMOTHY R (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:R
Last Name:HARBUCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 W GRANADA BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5941
Mailing Address - Country:US
Mailing Address - Phone:386-672-8934
Mailing Address - Fax:386-256-2007
Practice Address - Street 1:900 W GRANADA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5941
Practice Address - Country:US
Practice Address - Phone:386-672-8934
Practice Address - Fax:386-256-2007
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3348152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X, 152W00000X
FLOPC3448152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8934OtherVISION