Provider Demographics
NPI:1174637482
Name:BERRY, JON MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MARK
Last Name:BERRY
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 1:11601 TOEPPERWEIN RD
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3147
Mailing Address - Country:US
Mailing Address - Phone:210-946-2020
Mailing Address - Fax:210-590-3936
Practice Address - Street 1:11601 TOEPPERWEIN RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3147
Practice Address - Country:US
Practice Address - Phone:210-946-2020
Practice Address - Fax:210-590-3936
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9797207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084865701Medicaid
TX084865701Medicaid
00R67TMedicare ID - Type Unspecified