Provider Demographics
NPI:1730151127
Name:HARRIS, FREDERICK R (OD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:R
Last Name:HARRIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1941 HUNTINGTON DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4967
Mailing Address - Country:US
Mailing Address - Phone:626-799-2212
Mailing Address - Fax:626-799-4491
Practice Address - Street 1:1941 HUNTINGTON DR
Practice Address - Street 2:SUITE F
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4967
Practice Address - Country:US
Practice Address - Phone:626-799-2212
Practice Address - Fax:626-799-4491
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT4835T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0048350Medicaid
CADY4614Medicare PIN
0189780001Medicare NSC
T09792Medicare UPIN