Provider Demographics
NPI:1821078189
Name:HARRY, KEVIN A (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:A
Last Name:HARRY
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 STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:15300 WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2300
Practice Address - Country:US
Practice Address - Phone:262-786-9630
Practice Address - Fax:262-786-3972
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2179152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38575400Medicaid
000187994Medicare PIN
WIT21322Medicare UPIN
WI0866110001Medicare NSC