Provider Demographics
NPI:1962692152
Name:BERRY, MICHAEL EZRA (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EZRA
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICAHEL
Other - Middle Name:EZRA
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4037 74TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5603
Mailing Address - Country:US
Mailing Address - Phone:718-651-7000
Mailing Address - Fax:718-606-8966
Practice Address - Street 1:4037 74TH ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5603
Practice Address - Country:US
Practice Address - Phone:718-651-7000
Practice Address - Fax:718-606-8966
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245263207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology