Provider Demographics
NPI:1689087264
Name:BERRY, MARK (OMD, DMQ,)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:OMD, DMQ,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21044 SHERMAN WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-3648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21044 SHERMAN WAY STE 201
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-3648
Practice Address - Country:US
Practice Address - Phone:818-626-2695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133NN1002133NN1002X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education