Provider Demographics
NPI:1831376714
Name:ELIZABETH PROKOS BERRY
Entity type:Organization
Organization Name:ELIZABETH PROKOS BERRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:PROKOS
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:508-347-7309
Mailing Address - Street 1:135 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01566-1569
Mailing Address - Country:US
Mailing Address - Phone:508-347-7309
Mailing Address - Fax:
Practice Address - Street 1:135 MAIN ST
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566-1569
Practice Address - Country:US
Practice Address - Phone:508-347-7309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3274332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0371050Medicaid
MA429058Medicare PIN
MAT90915Medicare UPIN
MA1244800001Medicare NSC