Provider Demographics
NPI:1336190313
Name:BERRY, STACEY A (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:BERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-4847
Practice Address - Fax:682-885-6111
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35158207ZP0102X
TXQ9959207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ109624Medicare PIN
AZZ109623Medicare PIN