Provider Demographics
NPI:1073538104
Name:BERRIS, CRAIG EAGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:EAGAN
Last Name:BERRIS
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 1:77 SCRIPPS DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-6209
Mailing Address - Country:US
Mailing Address - Phone:916-929-6707
Mailing Address - Fax:916-929-6897
Practice Address - Street 1:77 SCRIPPS DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6209
Practice Address - Country:US
Practice Address - Phone:916-929-6707
Practice Address - Fax:916-929-6897
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32698174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G326980Medicaid
CA94269970OtherTAX ID
CA00G326980Medicaid
CA00G326980Medicare ID - Type Unspecified