Provider Demographics
NPI:1750361291
Name:BERRY, KYLE RUSSEL I (MD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:RUSSEL
Last Name:BERRY
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:23004 MINERVA DR
Mailing Address - Street 2:
Mailing Address - City:BRAMBLETON
Mailing Address - State:VA
Mailing Address - Zip Code:20148-6969
Mailing Address - Country:US
Mailing Address - Phone:703-542-5294
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0001
Practice Address - Country:US
Practice Address - Phone:301-295-4455
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101229038207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology