Provider Demographics
NPI:1336121938
Name:BERRY, MARK G (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:BERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 KENYON RD
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5776
Mailing Address - Country:US
Mailing Address - Phone:515-574-6840
Mailing Address - Fax:515-576-7726
Practice Address - Street 1:800 KENYON RD
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5776
Practice Address - Country:US
Practice Address - Phone:515-574-6840
Practice Address - Fax:515-576-7726
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03552207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0432666Medicaid
IAI03089Medicare UPIN
IA0432666Medicaid