Provider Demographics
NPI:1366572356
Name:BERRY, TRISTAN T (MD)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:T
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:PO BOX 43100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-3100
Mailing Address - Country:US
Mailing Address - Phone:520-722-3777
Mailing Address - Fax:520-296-6224
Practice Address - Street 1:2300 S HOUGHTON RD STE 240
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85748-0002
Practice Address - Country:US
Practice Address - Phone:520-203-7596
Practice Address - Fax:520-203-7936
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43352208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ525349Medicaid
AZZ180002Medicare PIN
AZ525349Medicaid
AZZ196072Medicare PIN
VA10019828OtherSENTARA OPTIMA
AZZ180002Medicare PIN