Provider Demographics
NPI:1558300343
Name:BERRY, ELEANOR (MD)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2507
Mailing Address - Country:US
Mailing Address - Phone:203-754-2535
Mailing Address - Fax:203-756-9921
Practice Address - Street 1:134 GRANDVIEW AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2507
Practice Address - Country:US
Practice Address - Phone:203-754-2535
Practice Address - Fax:203-756-9921
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036786207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001367863Medicaid
CT001367863Medicaid
CT160001770Medicare PIN
CT160001770Medicare ID - Type Unspecified