1942295381 NPI number — BRENDA BERRY MD

Table of content: BRENDA BERRY MD (NPI 1942295381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942295381 NPI number — BRENDA BERRY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERRY
Provider First Name:
BRENDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REGIER
Provider Other First Name:
BRENDA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1942295381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1290 E SPRUCE AVE STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93720-3371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-323-2145
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1290 E SPRUCE AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93720-3371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-431-2397
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  G85561 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G855610 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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