Provider Demographics
NPI:1235245259
Name:JAMES K. BERRY OD, PA
Entity Type:Organization
Organization Name:JAMES K. BERRY OD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:352-787-9799
Mailing Address - Street 1:1320 SHELFER ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-3929
Mailing Address - Country:US
Mailing Address - Phone:352-787-9799
Mailing Address - Fax:352-728-0057
Practice Address - Street 1:1320 SHELFER ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3929
Practice Address - Country:US
Practice Address - Phone:352-787-9799
Practice Address - Fax:352-728-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1901152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT84228Medicare UPIN
FL19806Medicare PIN