Healthcare Provider Details

I. General information

NPI: 1194613794
Provider Name (Legal Business Name): LATIFA BERRY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2025
Last Update Date: 06/24/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1769 WASHTENAW RD
YPSILANTI MI
48197-2020
US

IV. Provider business mailing address

30600 W. 12 MILE RD.
FARMINGTON HILLS MI
48334
US

V. Phone/Fax

Practice location:
  • Phone: 734-483-2100
  • Fax: 734-483-2060
Mailing address:
  • Phone: 248-737-3937
  • Fax: 248-737-2816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005895
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: