Provider Demographics
NPI:1194863183
Name:HARRIS, KEVIN RUSSELL (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RUSSELL
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 1:1641 BYRD RD
Mailing Address - Street 2:
Mailing Address - City:HARTSELLE
Mailing Address - State:AL
Mailing Address - Zip Code:35640-5907
Mailing Address - Country:US
Mailing Address - Phone:256-751-1125
Mailing Address - Fax:
Practice Address - Street 1:2620 CENTRON DR SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-2500
Practice Address - Country:US
Practice Address - Phone:256-350-6655
Practice Address - Fax:256-350-2548
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS813 TA107152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000-79209Medicaid
ALU58144Medicare UPIN