Provider Demographics
NPI:1699971796
Name:BERRY, MARC LANDON (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:LANDON
Last Name:BERRY
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 1:800 PRINCE FREDERICK BLVD
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-3145
Mailing Address - Country:US
Mailing Address - Phone:410-535-2270
Mailing Address - Fax:
Practice Address - Street 1:1160 VARNUM ST NE
Practice Address - Street 2:SUITE 317
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2107
Practice Address - Country:US
Practice Address - Phone:202-636-1130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0050937207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF48901Medicare UPIN