1104214311 NPI number — PATRICIA BERRY RD,LD,CDE

Table of content: PATRICIA BERRY RD,LD,CDE (NPI 1104214311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104214311 NPI number — PATRICIA BERRY RD,LD,CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERRY
Provider First Name:
PATRICIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD,LD,CDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104214311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12865 CAMINITO DEL CANTO
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEL MAR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92014-3758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-472-2184
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12526 HIGH BLUFF DR STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92130-2067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-375-3210
Provider Business Practice Location Address Fax Number:
858-205-1430
Provider Enumeration Date:
12/23/2014

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: 133V00000X , with the licence number:  DT83283 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 387305ZG8J . This is a "MEDICARE ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com