Healthcare Provider Details

I. General information

NPI: 1356326532
Provider Name (Legal Business Name): ELIZABETH PROKOS BERRY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 MAIN ST
STURBRIDGE MA
01566-1569
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 508-347-7309
  • Fax: 508-347-7451
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3274
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: