Provider Demographics
NPI:1033216676
Name:BERRIOS, JOSE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:A
Last Name:BERRIOS
Suffix:
Gender:M
Credentials:MD
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 105
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33595-0105
Mailing Address - Country:US
Mailing Address - Phone:813-657-1064
Mailing Address - Fax:813-654-7105
Practice Address - Street 1:320 OAKFIELD DRIVE SUITE D
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5742
Practice Address - Country:US
Practice Address - Phone:813-657-1064
Practice Address - Fax:813-654-7105
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME25337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066471500Medicaid
FLD10178Medicare UPIN
FL30705Medicare ID - Type Unspecified