Provider Demographics
NPI:1528014495
Name:BERRY, CHARLES KENNON SR (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KENNON
Last Name:BERRY
Suffix:SR
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 1:728 BRENDA AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-6038
Mailing Address - Country:US
Mailing Address - Phone:334-821-7646
Mailing Address - Fax:334-821-7646
Practice Address - Street 1:2900 PEPPERELL PARKWAY
Practice Address - Street 2:VISION CENTER STORE 0355
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801
Practice Address - Country:US
Practice Address - Phone:334-745-0980
Practice Address - Fax:334-745-6211
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS0425TA230152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT69128Medicare UPIN
AL51079600BERMedicare ID - Type Unspecified