Provider Demographics
NPI:1003420399
Name:HARADA, KYLE KIYOSHI (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:KIYOSHI
Last Name:HARADA
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 1:1010 STILLWELL DR UNIT 2422
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-6281
Mailing Address - Country:US
Mailing Address - Phone:408-438-3658
Mailing Address - Fax:
Practice Address - Street 1:1010 STILLWELL DR UNIT 2422
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6281
Practice Address - Country:US
Practice Address - Phone:408-438-3658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34666152W00000X
NC2620152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist