Provider Demographics
NPI:1689935850
Name:BERRY, BRANDON M (IDC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:M
Last Name:BERRY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11123 PEGASUS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4717
Mailing Address - Country:US
Mailing Address - Phone:714-403-3604
Mailing Address - Fax:
Practice Address - Street 1:11123 PEGASUS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4717
Practice Address - Country:US
Practice Address - Phone:714-403-3604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman