Provider Demographics
NPI:1639230089
Name:BERRY, EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
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 1:4403 HARRISON BLVD STE 3680
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3289
Mailing Address - Country:US
Mailing Address - Phone:801-387-3900
Mailing Address - Fax:801-387-3905
Practice Address - Street 1:4403 HARRISON BLVD STE 3680
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3289
Practice Address - Country:US
Practice Address - Phone:801-387-3900
Practice Address - Fax:801-387-3905
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT185322207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10602Medicaid
UT10602Medicaid
UTE61533Medicare UPIN