Provider Demographics
NPI:1710065230
Name:BERRY, BRUCE BART (MD)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:BART
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 1:2315 E MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-2939
Mailing Address - Country:US
Mailing Address - Phone:262-532-5700
Mailing Address - Fax:262-532-5701
Practice Address - Street 1:2315 E MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2939
Practice Address - Country:US
Practice Address - Phone:262-532-5700
Practice Address - Fax:262-532-5701
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25901207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30800800Medicaid
B51537Medicare UPIN
WI2356Medicare PIN
WI30800800Medicaid