Provider Demographics
NPI:1114000791
Name:HARRIS, KELVIN C (MD)
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:C
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 ABERDEEN BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0637
Mailing Address - Country:US
Mailing Address - Phone:704-865-2229
Mailing Address - Fax:704-865-2811
Practice Address - Street 1:2680 ABERDEEN BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0637
Practice Address - Country:US
Practice Address - Phone:704-865-2229
Practice Address - Fax:704-865-2811
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38774207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8939948Medicaid
SCN38774Medicaid
NC2151335GMedicare PIN
SCN38774Medicaid