Healthcare Provider Details

I. General information

NPI: 1275995714
Provider Name (Legal Business Name): JEFFERSON BERRYMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W KENT AVE
MISSOULA MT
59801-6772
US

IV. Provider business mailing address

700 W KENT AVE
MISSOULA MT
59801-6772
US

V. Phone/Fax

Practice location:
  • Phone: 406-541-3937
  • Fax: 406-541-3811
Mailing address:
  • Phone: 952-888-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number98709
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number98709
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: