Provider Demographics
NPI:1679688113
Name:BERRY, JAMES MONTGOMERY (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MONTGOMERY
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 2180
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-2180
Mailing Address - Country:US
Mailing Address - Phone:662-844-6513
Mailing Address - Fax:662-844-1113
Practice Address - Street 1:618 PEGRAM DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6322
Practice Address - Country:US
Practice Address - Phone:662-844-6513
Practice Address - Fax:662-844-1113
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13598207Y00000X, 207YX0602X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0119247Medicaid
MSG65774Medicare UPIN
MS0119247Medicaid