Basic Information
Provider Information | |||||||||
NPI: | 1649237223 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARRIS | ||||||||
FirstName: | ALLISON | ||||||||
MiddleName: | HATLEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HATLEY | ||||||||
OtherFirstName: | ANDREA | ||||||||
OtherMiddleName: | ALLISON | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1950 OLD GALLOWS RD | ||||||||
Address2: | SUITE 520 | ||||||||
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: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2006 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1389 | NC | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 09691 | 01 | NC | BCBS GROUP # | OTHER | 7909344 | 05 | NC |   | MEDICAID | 09344 | 01 | NC | BCBS PROV # | OTHER | 410018564 | 01 | NC | RAILROAD MCARE PROVIDER # | OTHER | DB8258 | 01 | NC | RR MCARE GROUP # | OTHER | 246648E | 01 | NC | MEDICARE GROUP # | OTHER | 8909691 | 01 | NC | MEDICAID GROUP # | OTHER | 0139010001 | 01 | NC | DMERC GROUP # | OTHER |