Provider Demographics
NPI:1235145327
Name:HARRIS, KENNETH CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHARLES
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 1:9220 SILVERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-7242
Mailing Address - Country:US
Mailing Address - Phone:916-337-0511
Mailing Address - Fax:
Practice Address - Street 1:9220 SILVERWOOD CT
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-7242
Practice Address - Country:US
Practice Address - Phone:916-337-0511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44882207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A448820OtherBLUE SHIELD
CA00A448820Medicaid
CABA054ZMedicare PIN
E45316Medicare UPIN
CA00A448820Medicaid