Provider Demographics
NPI:1720729239
Name:BERRY, JACK (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HAVEN AVE APT 21D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-2625
Mailing Address - Country:US
Mailing Address - Phone:301-787-8273
Mailing Address - Fax:
Practice Address - Street 1:100 HAVEN AVE APT 21D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-2625
Practice Address - Country:US
Practice Address - Phone:301-787-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program