Healthcare Provider Details

I. General information

NPI: 1205464294
Provider Name (Legal Business Name): KEVIN LEE HARRIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 INTERNATIONAL CIR
SAN JOSE CA
95119-1130
US

IV. Provider business mailing address

8414 NAAB RD
INDIANAPOLIS IN
46260-1972
US

V. Phone/Fax

Practice location:
  • Phone: 408-362-4791
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A21162
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: