Provider Demographics
NPI:1780667634
Name:BERRY, LEONARD AUTWOOD JR (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:AUTWOOD
Last Name:BERRY
Suffix:JR
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 860
Mailing Address - Street 2:
Mailing Address - City:HUTCHINS
Mailing Address - State:TX
Mailing Address - Zip Code:75141-0860
Mailing Address - Country:US
Mailing Address - Phone:972-225-0081
Mailing Address - Fax:972-225-0805
Practice Address - Street 1:9455 S LANCASTER HUTCHINS RD
Practice Address - Street 2:
Practice Address - City:HUTCHINS
Practice Address - State:TX
Practice Address - Zip Code:75141-3368
Practice Address - Country:US
Practice Address - Phone:972-225-0081
Practice Address - Fax:972-225-0805
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3620207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BN470OtherBCBS
TX1393175 17Medicaid
TXE50982Medicare UPIN
TX8BN470OtherBCBS