Provider Demographics
NPI:1811993694
Name:PHILLIPS, MICHAEL LORD (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LORD
Last Name:PHILLIPS
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 1:555 ELM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-3309
Mailing Address - Country:US
Mailing Address - Phone:508-699-8227
Mailing Address - Fax:508-699-2214
Practice Address - Street 1:555 ELM ST
Practice Address - Street 2:
Practice Address - City:NORTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02760-3309
Practice Address - Country:US
Practice Address - Phone:508-699-8227
Practice Address - Fax:508-699-2214
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-25
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030.0133967152W00000X
RIODTA00559152W00000X
WI3867-35152W00000X
FLTPOP103152W00000X
MA2778152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAT59286Medicare UPIN