Provider Demographics
NPI:1952480824
Name:BERRY, JONATHAN R (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:RONALD
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100-15TH AVE.
Mailing Address - Street 2:STE #180
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1160
Mailing Address - Country:US
Mailing Address - Phone:414-422-2120
Mailing Address - Fax:414-422-2185
Practice Address - Street 1:S74 W16775 JANESVILLE RD.
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-7742
Practice Address - Country:US
Practice Address - Phone:414-422-2180
Practice Address - Fax:414-422-2185
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301049407207X00000X
WI30106207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI68015-0042Medicare PIN
WI02170-0199Medicare PIN