Basic Information
| Provider Information | |||||||||
| NPI: | 1366572356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | TRISTAN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43100 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857333100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207223777 | ||||||||
| FaxNumber: | 5202966224 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 N EL DORADO PL | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857154606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203244660 | ||||||||
| FaxNumber: | 5203244659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 03/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 43352 | AZ | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 525349 | 05 | AZ | MEDICAID |