Basic Information
| Provider Information | |||||||||
| NPI: | 1285869834 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 GRAHAM ROAD WEST | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072572188 | ||||||||
| FaxNumber: | 6072667341 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 GRAHAM ROAD WEST | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072572188 | ||||||||
| FaxNumber: | 6072667341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2009 | ||||||||
| LastUpdateDate: | 11/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 266726 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.