Provider Demographics
NPI:1346731932
Name:BERRY, JONATHAN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:THOMAS
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11415 EXECUTIVE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4489
Mailing Address - Country:US
Mailing Address - Phone:501-224-5220
Mailing Address - Fax:501-228-9828
Practice Address - Street 1:11415 EXECUTIVE CENTER DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4489
Practice Address - Country:US
Practice Address - Phone:501-224-5220
Practice Address - Fax:501-228-9828
Is Sole Proprietor?:No
Enumeration Date:2018-05-20
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE-13520207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program