Healthcare Provider Details

I. General information

NPI: 1366572356
Provider Name (Legal Business Name): TRISTAN T BERRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 9TH AVE STE 120
LONGVIEW WA
98632-2465
US

IV. Provider business mailing address

PO BOX 43100
TUCSON AZ
85733-3100
US

V. Phone/Fax

Practice location:
  • Phone: 360-636-8950
  • Fax: 360-636-8951
Mailing address:
  • Phone: 520-722-3777
  • Fax: 520-296-6224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number43352
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number61299100
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: