Basic Information
| Provider Information | |||||||||
| NPI: | 1134212145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRELL | ||||||||
| FirstName: | STUART | ||||||||
| MiddleName: | KENT | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 407 AVENUE K SE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338804126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632943504 | ||||||||
| FaxNumber: | 8665223607 | ||||||||
| Practice Location | |||||||||
| Address1: | 2004 CR 540-A | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632943504 | ||||||||
| FaxNumber: | 8665223607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 04/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC2359 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 621353700 | 05 | FL | MEDICAID |