Provider Demographics
NPI:1215954219
Name:BERRY, SPENCER D (MD)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:D
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3175 SIENNA DR S
Mailing Address - Street 2:103
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8910
Mailing Address - Country:US
Mailing Address - Phone:701-205-3088
Mailing Address - Fax:701-335-7808
Practice Address - Street 1:3175 SIENNA DR S
Practice Address - Street 2:103
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8910
Practice Address - Country:US
Practice Address - Phone:701-205-3088
Practice Address - Fax:701-335-7808
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2012-03-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ND7514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D25167Medicare UPIN