Provider Demographics
NPI:1114032539
Name:BERRY, PHILLIP RAY (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:RAY
Last Name:BERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7514 S 107TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-2530
Mailing Address - Country:US
Mailing Address - Phone:918-252-0038
Mailing Address - Fax:
Practice Address - Street 1:1145 S UTICA AVE
Practice Address - Street 2:SUITE 453
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4000
Practice Address - Country:US
Practice Address - Phone:918-596-7078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3021207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1203021OtherDHS PRESCRIBER NUMBER
OKF-69132Medicare UPIN