1912961905 NPI number — DR. BUFORD EUGENE BERRY M.D.

Table of content: DR. BUFORD EUGENE BERRY M.D. (NPI 1912961905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912961905 NPI number — DR. BUFORD EUGENE BERRY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERRY
Provider First Name:
BUFORD
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912961905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2717 E LAKESHORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70808-2151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-387-2707
Provider Business Mailing Address Fax Number:
225-387-2718

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 HENNESSY BLVD
Provider Second Line Business Practice Location Address:
SUITE 1008
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70808-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-766-0416
Provider Business Practice Location Address Fax Number:
225-769-9212
Provider Enumeration Date:
04/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  02607R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00019705 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1130907 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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