Healthcare Provider Details

I. General information

NPI: 1316971740
Provider Name (Legal Business Name): ROBERT EUGENE BERRY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19200 PRESTON RD STE 120
DALLAS TX
75252-2450
US

IV. Provider business mailing address

19200 PRESTON RD STE 120
DALLAS TX
75252-2450
US

V. Phone/Fax

Practice location:
  • Phone: 469-200-2832
  • Fax: 469-269-1074
Mailing address:
  • Phone: 469-200-2832
  • Fax: 469-269-1074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number20A7616
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberM1511
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: