Provider Demographics
NPI:1538141924
Name:BERRY, RICHARD W (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
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 1:631 W 38TH ST STE 3
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1251
Mailing Address - Country:US
Mailing Address - Phone:512-459-1230
Mailing Address - Fax:512-459-3557
Practice Address - Street 1:631 W 38TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1250
Practice Address - Country:US
Practice Address - Phone:512-459-1238
Practice Address - Fax:512-459-3557
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-19
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00K31BOtherBCBS
TX00K31BMedicare PIN
C13423Medicare UPIN