Provider Demographics
NPI:1265693121
Name:LEONARD BERRY JR LLC
Entity type:Organization
Organization Name:LEONARD BERRY JR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:AUTWOOD
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:972-225-0081
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:HUTCHINS
Mailing Address - State:TX
Mailing Address - Zip Code:75141-0860
Mailing Address - Country:US
Mailing Address - Phone:972-225-0081
Mailing Address - Fax:972-225-0805
Practice Address - Street 1:9455 S LANCASTER HUTCHINS RD
Practice Address - Street 2:
Practice Address - City:HUTCHINS
Practice Address - State:TX
Practice Address - Zip Code:75141-3368
Practice Address - Country:US
Practice Address - Phone:972-225-0081
Practice Address - Fax:972-225-0805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3620207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139317516Medicaid
TX139317516Medicaid
TX8F9310Medicare PIN