Provider Demographics
NPI:1942295381
Name:BERRY, BRENDA (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:REGIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1290 E SPRUCE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3371
Mailing Address - Country:US
Mailing Address - Phone:559-323-2145
Mailing Address - Fax:
Practice Address - Street 1:1290 E SPRUCE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3371
Practice Address - Country:US
Practice Address - Phone:559-431-2397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G855610Medicaid
CA00G855610Medicaid
CA110235685Medicare PIN
CA00G855610Medicare PIN