Provider Demographics
NPI:1619971397
Name:FARRIS, MICHAEL DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DOUGLAS
Last Name:FARRIS
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 1:113 COUNTRY CLUB DR NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2935
Mailing Address - Country:US
Mailing Address - Phone:704-786-7600
Mailing Address - Fax:704-792-2131
Practice Address - Street 1:113 COUNTRY CLUB DR NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2935
Practice Address - Country:US
Practice Address - Phone:704-786-7600
Practice Address - Fax:704-792-2131
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1117152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890914JMedicaid
NC1117OtherSTATE LICENSE
NC246520AMedicare ID - Type Unspecified
NC1117OtherSTATE LICENSE