Provider Demographics
NPI:1275995714
Name:BERRYMAN, JEFFERSON
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:
Last Name:BERRYMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W KENT AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6772
Mailing Address - Country:US
Mailing Address - Phone:952-888-5800
Mailing Address - Fax:
Practice Address - Street 1:700 W KENT AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6772
Practice Address - Country:US
Practice Address - Phone:406-541-3937
Practice Address - Fax:406-541-3811
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT98709207WX0009X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist