Provider Demographics
NPI:1306956768
Name:BERRY, DANIEL WALTER (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:WALTER
Last Name:BERRY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1092 N STATE COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-2701
Mailing Address - Country:US
Mailing Address - Phone:714-635-8671
Mailing Address - Fax:714-635-9401
Practice Address - Street 1:1092 N STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2701
Practice Address - Country:US
Practice Address - Phone:714-635-8671
Practice Address - Fax:714-635-9401
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4870T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0048700Medicaid
T69961Medicare UPIN