Provider Demographics
NPI:1669470704
Name:BERRY, RICHARD PHILLIP (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PHILLIP
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:PO BOX 703
Mailing Address - Street 2:
Mailing Address - City:SHATTUCK
Mailing Address - State:OK
Mailing Address - Zip Code:73858-0703
Mailing Address - Country:US
Mailing Address - Phone:580-938-5275
Mailing Address - Fax:580-938-2256
Practice Address - Street 1:905 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHATTUCK
Practice Address - State:OK
Practice Address - Zip Code:73858-9205
Practice Address - Country:US
Practice Address - Phone:580-938-5275
Practice Address - Fax:580-938-2256
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100137950AMedicaid
OKF64360Medicare UPIN
OK$$$$$$$$$PMedicare PIN