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General NPI Number Information
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NPI Number | 1376771980
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Entity Type | Individual
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Provider Name | MICAH DIAZ BERRY M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/23/2009
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Last Update Date | 02/01/2021
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Provider Practice Location Address
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Address Line | 710 MIRA MONTE PL
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City | PASADENA
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State | CA
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Zip | 91101-2521
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Country | US
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Telephone | 310-569-5933
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Fax |
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Provider Business Mailing Address
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Address Line | 300 SIERRA COLLEGE DR STE 250
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City | GRASS VALLEY
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State | CA
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Zip | 95945-5083
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Country | US
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Telephone | 530-477-0011
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | A110714
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License Number State | CA
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