Provider Demographics
NPI:1356326532
Name:BERRY, ELIZABETH PROKOS (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:PROKOS
Last Name:BERRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:135 MAIN ST
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566-1569
Practice Address - Country:US
Practice Address - Phone:508-347-7309
Practice Address - Fax:508-347-7451
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-12
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3274152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW15758OtherBCBS
MA759056OtherTUFTS
MA0371050Medicaid
MA759056OtherTUFTS
MA0371050Medicaid