Provider Demographics
NPI:1487638425
Name:BERRY, JEFFREY G (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:G
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:PO BOX 5366
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-5366
Mailing Address - Country:US
Mailing Address - Phone:660-826-5960
Mailing Address - Fax:660-826-4852
Practice Address - Street 1:1111 N LEE AVE
Practice Address - Street 2:STE 236
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2600
Practice Address - Country:US
Practice Address - Phone:405-524-4105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19893207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00643961OtherRR MEDICARE
OK100047890AMedicaid
OK100047890AMedicaid
G91618Medicare UPIN