Provider Demographics
NPI:1295744555
Name:BERRY, BRIAN J (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 40TH ST W
Mailing Address - Street 2:STE 100
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4318
Mailing Address - Country:US
Mailing Address - Phone:253-564-0170
Mailing Address - Fax:253-207-4240
Practice Address - Street 1:7210 40TH ST W
Practice Address - Street 2:STE 100
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4318
Practice Address - Country:US
Practice Address - Phone:253-564-0170
Practice Address - Fax:253-207-4240
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024170208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA370013712OtherRAILROAD
WA8930009OtherSTATE CRIME VICTIMS
WA1021823Medicaid
WA0129626OtherSTATE L&I
WA8939534OtherSTATE CRIME VICTIMS
WA0205806OtherSTATE L&I
WA0192336OtherSTATE L&I
WA8940788OtherSTATE CRIME VICTIMS
WA0129626OtherSTATE L&I
WAG8858630Medicare PIN
WA8939534OtherSTATE CRIME VICTIMS
WA1021823Medicaid