Basic Information
Provider Information
NPI: 1003013343
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BERRY
FirstName: TIFFANY
MiddleName: JONES
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 14051 WEDEL CEMETERY RD
Address2:  
City: ROGERS
State: TX
PostalCode: 765693790
CountryCode: US
TelephoneNumber: 2544931557
FaxNumber:  
Practice Location
Address1: 2401 S 31ST ST
Address2:  
City: TEMPLE
State: TX
PostalCode: 765080001
CountryCode: US
TelephoneNumber: 2547246927
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/29/2007
LastUpdateDate: 08/20/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XM7041TXY Allopathic & Osteopathic PhysiciansFamily Medicine 
390200000X  N Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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