Provider Demographics
NPI:1104898220
Name:HARRISON, BRET W (OD)
Entity type:Individual
Prefix:DR
First Name:BRET
Middle Name:W
Last Name:HARRISON
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 1:6140 TUTT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-3575
Mailing Address - Country:US
Mailing Address - Phone:719-268-1010
Mailing Address - Fax:719-375-5444
Practice Address - Street 1:6140 TUTT BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-3575
Practice Address - Country:US
Practice Address - Phone:719-268-1010
Practice Address - Fax:719-375-5444
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1128152W00000X
COOPT.0001128152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO840922826OtherEIN NUMBER
CO840922826OtherEIN NUMBER
COT92263Medicare UPIN