Provider Demographics
NPI:1851939326
Name:THAVALATHIL, BERRY CHERIYAN (MD)
Entity Type:Individual
Prefix:
First Name:BERRY
Middle Name:CHERIYAN
Last Name:THAVALATHIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BERRY
Other - Middle Name:CHERIYAN
Other - Last Name:THAVALATHIL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:921 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5007
Mailing Address - Country:US
Mailing Address - Phone:787-653-6060
Mailing Address - Fax:
Practice Address - Street 1:921 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5007
Practice Address - Country:US
Practice Address - Phone:405-456-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21860261QR1300X, 261QP2300X
PR15187I390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1851939326OtherN/A