Provider Demographics
NPI:1477514420
Name:BERRY, GREGORY J (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:BERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 PENN AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50316-2339
Mailing Address - Country:US
Mailing Address - Phone:515-266-1000
Mailing Address - Fax:515-266-1824
Practice Address - Street 1:1201 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2339
Practice Address - Country:US
Practice Address - Phone:515-266-1000
Practice Address - Fax:515-266-1824
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3525207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0416032Medicaid
IA1477514420Medicaid
G70208Medicare UPIN
IA1477514420Medicaid
IAI10369Medicare PIN
IA719260456Medicare PIN