Provider Demographics
NPI:1013992668
Name:HARRIS, ANGELA STACK (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:STACK
Last Name:HARRIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ANGELA
Other - Middle Name:RAYE
Other - Last Name:STACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:548 WILLIAMSON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9111
Mailing Address - Country:US
Mailing Address - Phone:704-799-2233
Mailing Address - Fax:704-799-1567
Practice Address - Street 1:548 WILLIAMSON RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-799-2233
Practice Address - Fax:704-799-1567
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1589152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890900TMedicaid
NCU61143Medicare UPIN
NC890900TMedicaid