Provider Demographics
NPI:1902014277
Name:KEVIN A. HARRY, O.D.
Entity Type:Organization
Organization Name:KEVIN A. HARRY, O.D.
Other - Org Name:SIGNATURE EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER-OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HARRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-786-9630
Mailing Address - Street 1:17125 W BLUEMOUND RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5948
Mailing Address - Country:US
Mailing Address - Phone:262-786-9630
Mailing Address - Fax:262-786-3972
Practice Address - Street 1:17125 W BLUEMOUND RD
Practice Address - Street 2:SUITE F
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5948
Practice Address - Country:US
Practice Address - Phone:262-786-9630
Practice Address - Fax:262-786-3972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-19
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI 2179152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38575400Medicaid
WI38575400Medicaid
WIT21322Medicare UPIN
WI0866110001Medicare NSC