Provider Demographics
NPI:1427027754
Name:BERRY, JONATHAN DALE (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DALE
Last Name:BERRY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 HERITAGE WAY SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-8600
Mailing Address - Country:US
Mailing Address - Phone:541-926-6077
Mailing Address - Fax:541-926-0605
Practice Address - Street 1:2330 HERITAGE WAY SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-8600
Practice Address - Country:US
Practice Address - Phone:541-926-6077
Practice Address - Fax:541-926-0605
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATI3122152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR270040Medicaid
OR009446008OtherREGENCE BC BS
ORMB1289708OtherDRUG NUMBER
ORMB1289708OtherDRUG NUMBER
ORV06156Medicare UPIN