Provider Demographics
NPI:1497756183
Name:BERRY, RICHARD S (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
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 1:2820 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-7958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2820 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7958
Practice Address - Country:US
Practice Address - Phone:718-996-3000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
NY124011174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4095409OtherAETNA
NYMCA058903OtherAMERICHOICE
NY161917OtherELDERPLAN
NY00233096Medicaid
NY0033804OtherGHI
NY90436OtherAETNA
NYDS086OtherOXFORD
NY124011OtherHIP
NY973731Medicare ID - Type Unspecified
NYB80261Medicare UPIN