Provider Demographics
NPI:1164434056
Name:POWELL, BERKLEY RANDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:BERKLEY
Middle Name:RANDOLPH
Last Name:POWELL
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 1:9300 VALLEY CHILDRENS PL
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-6400
Mailing Address - Fax:559-353-7213
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-8761
Practice Address - Country:US
Practice Address - Phone:559-353-6400
Practice Address - Fax:559-353-7213
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85858207SG0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC94158Medicare UPIN
CA00G858580Medicare ID - Type Unspecified