Provider Demographics
NPI:1508859638
Name:HARRISON, KURT DUDLEY (DO)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:DUDLEY
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 GLEN SPRINGS DR.
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420
Mailing Address - Country:US
Mailing Address - Phone:419-333-9026
Mailing Address - Fax:419-333-9043
Practice Address - Street 1:1922 GLEN SPRINGS DR.
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420
Practice Address - Country:US
Practice Address - Phone:419-333-9026
Practice Address - Fax:419-333-9043
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007809207V00000X
OH34007809H207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2307739Medicaid
OH2307739Medicaid
OH2307739Medicaid
OHH57546Medicare UPIN