Provider Demographics
NPI:1295815140
Name:BERRY, MICHAEL D (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:BERRY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E KATELLA AVE
Mailing Address - Street 2:SUITE O
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-6302
Mailing Address - Country:US
Mailing Address - Phone:714-639-4640
Mailing Address - Fax:714-639-5628
Practice Address - Street 1:1500 E KATELLA AVE
Practice Address - Street 2:SUITE O
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-6302
Practice Address - Country:US
Practice Address - Phone:714-639-4640
Practice Address - Fax:714-639-5628
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC11854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0118540AOtherBLUE SHIELD IDENTIFIER
CADC0118540AOtherBLUE SHIELD IDENTIFIER
CAT04518Medicare UPIN