Basic Information
| Provider Information | |||||||||
| NPI: | 1497828776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHARRIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 EAST BIJOU | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 2857 E FOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809102312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193291221 | ||||||||
| FaxNumber: | 7193291511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WP0200X | 1462 | CO | Y | Eye and Vision Services Providers | Optometrist | Pediatrics | 152W00000X | 1462 | CO | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 21351821 | 05 | CO | MEDICAID | 08014623 | 05 | CO | MEDICAID |