Healthcare Provider Details

I. General information

NPI: 1689616567
Provider Name (Legal Business Name): JAMES KEVIN HARDISON D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 BILLINGSLEY RD SUITE 102
CHARLOTTE NC
28211-1040
US

IV. Provider business mailing address

335 BILLINGSLEY RD SUITE 102
CHARLOTTE NC
28211-1040
US

V. Phone/Fax

Practice location:
  • Phone: 704-632-8032
  • Fax: 704-632-8034
Mailing address:
  • Phone: 704-632-8032
  • Fax: 704-632-8034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number475
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: