Healthcare Provider Details

I. General information

NPI: 1649264482
Provider Name (Legal Business Name): DAVID BLAKE PHARIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date: 03/25/2006
Reactivation Date: 04/03/2006

III. Provider practice location address

3855 PLEASANT HILL RD SUITE 200
DULUTH GA
30096-1407
US

IV. Provider business mailing address

3855 PLEASANT HILL RD SUITE 200
DULUTH GA
30096-1407
US

V. Phone/Fax

Practice location:
  • Phone: 770-622-6861
  • Fax: 770-622-6862
Mailing address:
  • Phone: 770-622-6861
  • Fax: 770-681-6862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number045108
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: