Healthcare Provider Details

I. General information

NPI: 1285939330
Provider Name (Legal Business Name): ROBERT E. BERRY, DO, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5471 KEARNY VILLA RD. SUITE 200
SAN DIEGO CA
92123-1143
US

IV. Provider business mailing address

5471 KEARNY VILLA RD. SUITE 200
SAN DIEGO CA
92123-1143
US

V. Phone/Fax

Practice location:
  • Phone: 858-571-0606
  • Fax:
Mailing address:
  • Phone: 858-571-0606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number20A7616
License Number StateCA

VIII. Authorized Official

Name: MS. BEVERLY ANN MIZE
Title or Position: CREDENTIALING SPECIALIST
Credential: RHIT
Phone: 858-427-9203