Provider Demographics
NPI:1447364294
Name:HARRIS, TIMOTHY W (DO)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:HARRIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 S WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037-2018
Mailing Address - Country:US
Mailing Address - Phone:609-567-0200
Mailing Address - Fax:609-704-1482
Practice Address - Street 1:238 E BROADWAY
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NJ
Practice Address - Zip Code:08079-1108
Practice Address - Country:US
Practice Address - Phone:856-935-7711
Practice Address - Fax:856-935-9123
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06944700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8066906Medicaid
NJH16481Medicare UPIN
NJ038154Medicare ID - Type UnspecifiedMEDICARE NUMBER