Basic Information
| Provider Information | |||||||||
| NPI: | 1962500280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 137 PASTURE DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031024961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036239834 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1875 S WILLOW ST | ||||||||
| Address2: | MERRIMACK VISION CARE | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031032363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036446100 | ||||||||
| FaxNumber: | 6033140404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 152W00000X | NH616 | NH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 30350210 | 05 | NH | MEDICAID |