Provider Demographics
NPI:1568449783
Name:BERRY, MARY SUE ILLIONS (DO)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUE ILLIONS
Last Name:BERRY
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Gender:F
Credentials:DO
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Mailing Address - Street 1:500 S ANAHEIM HILLS RD
Mailing Address - Street 2:SUITE 242
Mailing Address - City:ANAHEIM HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4780
Mailing Address - Country:US
Mailing Address - Phone:714-974-0611
Mailing Address - Fax:714-221-2299
Practice Address - Street 1:500 S ANAHEIM HILLS RD
Practice Address - Street 2:SUITE 242
Practice Address - City:ANAHEIM HILLS
Practice Address - State:CA
Practice Address - Zip Code:92807-4780
Practice Address - Country:US
Practice Address - Phone:714-974-0611
Practice Address - Fax:714-221-2299
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2013-09-26
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Provider Licenses
StateLicense IDTaxonomies
CA20A7048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A7048OtherMEDICAL LIC
CAHB831AMedicare PIN