Provider Demographics
NPI:1942447578
Name:BERRY, DAVID GLASS (NMT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:GLASS
Last Name:BERRY
Suffix:
Gender:M
Credentials:NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3785
Mailing Address - Country:US
Mailing Address - Phone:843-899-9088
Mailing Address - Fax:843-899-9088
Practice Address - Street 1:202 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3785
Practice Address - Country:US
Practice Address - Phone:843-899-9088
Practice Address - Fax:843-899-9088
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5374171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor