Provider Demographics
NPI:1376771980
Name:BERRY, MICAH DIAZ (MD)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:DIAZ
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SIERRA COLLEGE DR
Mailing Address - Street 2:STE 250
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5083
Mailing Address - Country:US
Mailing Address - Phone:530-477-0011
Mailing Address - Fax:
Practice Address - Street 1:710 MIRA MONTE PL
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2521
Practice Address - Country:US
Practice Address - Phone:310-569-5933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA110714207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery