Provider Demographics
NPI:1063616290
Name:HARRIS, KENNON (MD)
Entity type:Individual
Prefix:DR
First Name:KENNON
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 MAYO RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-2951
Mailing Address - Country:US
Mailing Address - Phone:410-956-6303
Mailing Address - Fax:410-956-6303
Practice Address - Street 1:224 MAYO RD
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-2951
Practice Address - Country:US
Practice Address - Phone:410-956-6303
Practice Address - Fax:410-956-6637
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0065603208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics