Provider Demographics
NPI:1033194527
Name:BERRY, MICHELLE D (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:BERRY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-0339
Mailing Address - Country:US
Mailing Address - Phone:830-249-6000
Mailing Address - Fax:830-816-6002
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:STE 110
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2833
Practice Address - Country:US
Practice Address - Phone:830-249-6000
Practice Address - Fax:830-816-6002
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9798207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0919698-01Medicaid
TX0919698-01Medicaid
TX8F21293Medicare PIN