Healthcare Provider Details

I. General information

NPI: 1114032539
Provider Name (Legal Business Name): PHILLIP RAY BERRY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 S UTICA AVE SUITE 453
TULSA OK
74104-4000
US

IV. Provider business mailing address

7514 S 107TH EAST AVE
TULSA OK
74133-2530
US

V. Phone/Fax

Practice location:
  • Phone: 918-596-7078
  • Fax:
Mailing address:
  • Phone: 918-252-0038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number3021
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: