=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033216676
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE A BERRIOS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2006
-----------------------------------------------------
Last Update Date | 06/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 OAKFIELD DRIVE SUITE D
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-5742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-657-1064
-----------------------------------------------------
Fax | 813-654-7105
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 105
-----------------------------------------------------
City | VALRICO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33595-0105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-657-1064
-----------------------------------------------------
Fax | 813-654-7105
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME25337
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------