Provider Demographics
NPI:1023014750
Name:MIOUX BERRY, MARY A (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MIOUX BERRY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:MIOUX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:630 S RAYMOND AVE
Mailing Address - Street 2:SUITE #120
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3278
Mailing Address - Country:US
Mailing Address - Phone:626-403-1444
Mailing Address - Fax:626-403-1448
Practice Address - Street 1:630 S RAYMOND AVE
Practice Address - Street 2:SUITE #120
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3278
Practice Address - Country:US
Practice Address - Phone:626-403-1444
Practice Address - Fax:626-403-1448
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084547208100000X
CA20A8359208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL250004104OtherRAILROAD MEDICAID
IL0006005217OtherBLUE CROSS BLUE SHIELD
IL0006005217OtherBLUE CROSS BLUE SHIELD
IL250004104OtherRAILROAD MEDICAID