Provider Demographics
NPI:1902876311
Name:RISK, KENT JAMES (OD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:JAMES
Last Name:RISK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 NORTHSTONE PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5494
Mailing Address - Country:US
Mailing Address - Phone:910-527-9517
Mailing Address - Fax:
Practice Address - Street 1:216 NORTHSTONE PL
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5494
Practice Address - Country:US
Practice Address - Phone:910-527-9517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1555152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0900EOtherBLUE CROSS BLUE SHIELD
NC2238851OtherUNITED HEALTHCARE
NC890900EMedicaid
NC2460013AMedicare ID - Type Unspecified
NC890900EMedicaid