MEDICARE: PAUL S. BERRY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	G72073	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G72073	OTHER	CA	STAE LICENSE PHYSICIAN
2	00G720730	OTHER	CA	MEDI-CAL

General Provider Information

NPI Number	:	1740270891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL S. BERRY MD

Provider Business Mailing Address
First Line	:	216 I ST
Second Line	:	A-165
City	:	PATTERSON
State	:	CA
Zip	:	95363-2301
Country	:	US
Telephone Number	:	510-541-8784
Fax Number	:	209-892-9102

Provider Business Practice Location Address
First Line	:	1108 WARD AVE
Second Line	:	STE A
City	:	PATTERSON
State	:	CA
Zip	:	95363-8529
Country	:	US
Telephone Number	:	510-541-8784
Fax Number	:	209-892-9102

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	03/07/2023

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