Provider Demographics
NPI:1790808608
Name:O BERRY, MATTHEW D (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:O BERRY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 W. CLEVELAND ST.
Mailing Address - Street 2:PO BOX 1002
Mailing Address - City:NAHUNTA
Mailing Address - State:GA
Mailing Address - Zip Code:31553-1002
Mailing Address - Country:US
Mailing Address - Phone:912-462-7145
Mailing Address - Fax:
Practice Address - Street 1:143 W. CLEVELAND ST.
Practice Address - Street 2:
Practice Address - City:NAHUNTA
Practice Address - State:GA
Practice Address - Zip Code:31553-1002
Practice Address - Country:US
Practice Address - Phone:912-462-7145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5718111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCDSVMedicare ID - Type Unspecified
GAU66560Medicare UPIN