Provider Demographics
NPI:1689697310
Name:BERRY, GABRIEL (MD)
Entity Type:Individual
Prefix:
First Name:GABRIEL
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:PO BOX 889
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-0889
Mailing Address - Country:US
Mailing Address - Phone:850-638-1610
Mailing Address - Fax:
Practice Address - Street 1:1360 BRICKYARD RD
Practice Address - Street 2:
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-6303
Practice Address - Country:US
Practice Address - Phone:850-415-8180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFLME0091050208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270506100Medicaid
FL270506100Medicaid
48731ZMedicare ID - Type Unspecified