Provider Demographics
NPI:1801091806
Name:BERRY, JOHNATHON ALLEN (DO)
Entity type:Individual
Prefix:DR
First Name:JOHNATHON
Middle Name:ALLEN
Last Name:BERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13880 CLYDESDALE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-7339
Mailing Address - Country:US
Mailing Address - Phone:910-257-4361
Mailing Address - Fax:
Practice Address - Street 1:12001 HIGHWAY 71 S
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57747
Practice Address - Country:US
Practice Address - Phone:605-745-8910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.163599207P00000X
TXQ2248207P00000X
SD11969207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine