Healthcare Provider Details

I. General information

NPI: 1639816382
Provider Name (Legal Business Name): NICHOLAS ALEX BERRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2022
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 E 17TH ST STE W248
SANTA ANA CA
92701-2205
US

IV. Provider business mailing address

1125 E 17TH ST STE W248
SANTA ANA CA
92701-2205
US

V. Phone/Fax

Practice location:
  • Phone: 714-547-5151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA211678
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: