Provider Demographics
NPI:1033390190
Name:BERRY, JAMES KEVIN (OD, PA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:KEVIN
Last Name:BERRY
Suffix:
Gender:M
Credentials:OD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 SHELFER ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-3929
Mailing Address - Country:US
Mailing Address - Phone:352-787-9799
Mailing Address - Fax:352-728-0057
Practice Address - Street 1:1320 SHELFER ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3929
Practice Address - Country:US
Practice Address - Phone:352-787-9799
Practice Address - Fax:352-728-0057
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1901152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078738800Medicaid
FL078738800Medicaid
FLT8448Medicare UPIN