Provider Demographics
NPI:1316971740
Name:BERRY, ROBERT EUGENE (DO)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EUGENE
Last Name:BERRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19200 PRESTON RD STE 120
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-2450
Mailing Address - Country:US
Mailing Address - Phone:469-200-2832
Mailing Address - Fax:469-269-1074
Practice Address - Street 1:19200 PRESTON RD STE 120
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-2450
Practice Address - Country:US
Practice Address - Phone:469-200-2832
Practice Address - Fax:469-269-1074
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7616207XX0005X
TXM1511207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174448403Medicaid
TXP01083126Medicare PIN
TX174448403Medicaid