Provider Demographics
NPI:1376510230
Name:W E BERRY OD PA
Entity Type:Organization
Organization Name:W E BERRY OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILBURN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-766-9118
Mailing Address - Street 1:3750 CLEMMONS RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8499
Mailing Address - Country:US
Mailing Address - Phone:336-766-9118
Mailing Address - Fax:
Practice Address - Street 1:3750 CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8499
Practice Address - Country:US
Practice Address - Phone:336-766-9118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2467511Medicare ID - Type UnspecifiedOPTOMETRIST
NC0177170001Medicare NSC