Provider Demographics
NPI:1649264482
Name:PHARIS, DAVID BLAKE (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BLAKE
Last Name:PHARIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 PLEASANT HILL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1407
Mailing Address - Country:US
Mailing Address - Phone:770-622-6861
Mailing Address - Fax:770-681-6862
Practice Address - Street 1:3855 PLEASANT HILL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1407
Practice Address - Country:US
Practice Address - Phone:770-622-6861
Practice Address - Fax:770-622-6862
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2013-08-30
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
GA045108207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G702992Medicare PIN
GA202I072991Medicare PIN
GAP00906878Medicare PIN
07BBSJNMedicare ID - Type Unspecified
GADR1616Medicare PIN
H44008Medicare UPIN