Provider Demographics
NPI:1083889638
Name:BERRY, KEVIN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ANDREW
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:MS 315010
Mailing Address - Street 2:PO BOX 3947
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3947
Mailing Address - Country:US
Mailing Address - Phone:425-688-5670
Mailing Address - Fax:425-635-6388
Practice Address - Street 1:1740 NW MAPLE ST
Practice Address - Street 2:SUITE 111
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027
Practice Address - Country:US
Practice Address - Phone:425-394-1200
Practice Address - Fax:425-394-0100
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD60387536208100000X
ORMD86581208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2074986Medicaid