Provider Demographics
NPI:1639179153
Name:BERRY, BILL WAYNE JR (MD)
Entity Type:Individual
Prefix:
First Name:BILL
Middle Name:WAYNE
Last Name:BERRY
Suffix:JR
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 1:1950 GLENN MITCHELL DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-0019
Mailing Address - Country:US
Mailing Address - Phone:757-507-0340
Mailing Address - Fax:757-507-0341
Practice Address - Street 1:1950 GLENN MITCHELL DR
Practice Address - Street 2:SUITE 310
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-0019
Practice Address - Country:US
Practice Address - Phone:757-507-0340
Practice Address - Fax:757-507-0341
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054182207Y00000X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG35310Medicare UPIN