Provider Demographics
NPI:1225086093
Name:BERRETH, KYLA K (D O)
Entity Type:Individual
Prefix:DR
First Name:KYLA
Middle Name:K
Last Name:BERRETH
Suffix:
Gender:F
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2922
Mailing Address - Country:US
Mailing Address - Phone:434-799-2111
Mailing Address - Fax:
Practice Address - Street 1:201 S MAIN ST
Practice Address - Street 2:SUITE 2100
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2927
Practice Address - Country:US
Practice Address - Phone:434-799-2111
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201180208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH36441Medicare UPIN