Provider Demographics
NPI:1033485453
Name:BERRY, MIKE PRESTON JR (MD)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:PRESTON
Last Name:BERRY
Suffix:JR
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 1:1600 WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1799
Mailing Address - Country:US
Mailing Address - Phone:806-212-2000
Mailing Address - Fax:806-212-2735
Practice Address - Street 1:1600 WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1799
Practice Address - Country:US
Practice Address - Phone:806-212-2000
Practice Address - Fax:806-212-2735
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT87223207P00000X
NMMD2015-0299207P00000X
390200000X
TXQ5349207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program