Provider Demographics
NPI:1396735981
Name:BERRYMAN, JOHN DAVID (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:BERRYMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-4349
Mailing Address - Country:US
Mailing Address - Phone:202-270-1001
Mailing Address - Fax:
Practice Address - Street 1:200 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6444
Practice Address - Country:US
Practice Address - Phone:304-255-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20020275207V00000X
WAMD25778207V00000X
VA0101018540207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65653041Medicaid
NMNM009X99OtherHMO OF NEW MEXICO
NM10013194OtherLOVELACE SALUD
NMNM009X99OtherBCBS OF NEW MEXICO
NM10013194OtherLOVELACE HEALTH PLAN
NMQMYPR0067187OtherMOLINA SALUD
NMNM009X99OtherBCBS OF NEW MEXICO