Provider Demographics
NPI:1104826387
Name:HARRIS, KIRK RANDALL (OD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:RANDALL
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 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:1302 BROWN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-4672
Practice Address - Country:US
Practice Address - Phone:252-946-7257
Practice Address - Fax:252-946-9497
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1419152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0139010001OtherDMERC GROUP #
NC09691OtherBCBS GROUP #
NC410018240OtherRAILROAD MCARE PROVIDER #
NC890913EMedicaid
NC246648EOtherMEDICARE GROUP #
NC0913EOtherBCBS PROV #
NC8909691OtherMEDICAID GROUP #
NCDB8258OtherRAILROAD MEDICARE GRP #
NC0913EOtherBCBS PROV #
U25433Medicare UPIN