Healthcare Provider Details

I. General information

NPI: 1902014277
Provider Name (Legal Business Name): KEVIN A. HARRY, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2007
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17125 W BLUEMOUND RD SUITE F
BROOKFIELD WI
53005-5948
US

IV. Provider business mailing address

17125 W BLUEMOUND RD SUITE F
BROOKFIELD WI
53005-5948
US

V. Phone/Fax

Practice location:
  • Phone: 262-786-9630
  • Fax: 262-786-3972
Mailing address:
  • Phone: 262-786-9630
  • Fax: 262-786-3972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberWI 2179
License Number StateWI

VIII. Authorized Official

Name: KEVIN ALLEN HARRY
Title or Position: OWNER-OPTOMETRIST
Credential: OD
Phone: 262-786-9630