Healthcare Provider Details

I. General information

NPI: 1710896634
Provider Name (Legal Business Name): MADELINE ELISE BERRY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELINE KNUTSON

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6314 19TH ST W STE 1
FIRCREST WA
98466-6223
US

IV. Provider business mailing address

1538 COMMERCE ST
TACOMA WA
98402-3307
US

V. Phone/Fax

Practice location:
  • Phone: 253-566-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD.OD.70128354
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: