Healthcare Provider Details

I. General information

NPI: 1194924100
Provider Name (Legal Business Name): KEVIN THOMAS HARLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S CITY TOWER, SUITE 400
ORANGE CA
92868-3201
US

IV. Provider business mailing address

13135 LEE JACKSON MEMORIAL HWY STE 135
FAIRFAX VA
22033-1907
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5142
  • Fax:
Mailing address:
  • Phone: 703-961-0488
  • Fax: 703-961-0480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA98051
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01010263559
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: