Basic Information
| Provider Information | |||||||||
| NPI: | 1104826387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | KIRK | ||||||||
| MiddleName: | RANDALL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 7039910514 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 BROWN ST | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278894672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529467257 | ||||||||
| FaxNumber: | 2529469497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1419 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0139010001 | 01 | NC | DMERC GROUP # | OTHER | 09691 | 01 | NC | BCBS GROUP # | OTHER | 410018240 | 01 | NC | RAILROAD MCARE PROVIDER # | OTHER | 890913E | 05 | NC | MEDICAID | 246648E | 01 | NC | MEDICARE GROUP # | OTHER | 0913E | 01 | NC | BCBS PROV # | OTHER | 8909691 | 01 | NC | MEDICAID GROUP # | OTHER | DB8258 | 01 | NC | RAILROAD MEDICARE GRP # | OTHER |