Provider Demographics
NPI:1871578070
Name:BERRY, DEAINA M (MD)
Entity type:Individual
Prefix:
First Name:DEAINA
Middle Name:M
Last Name:BERRY
Suffix:
Gender:F
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 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9202 ELAM RD
Practice Address - Street 2:SOUTHEAST DALLAS HEALTH CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-4151
Practice Address - Country:US
Practice Address - Phone:214-266-1600
Practice Address - Fax:214-266-1790
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2012-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7306208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139121110Medicaid
TX139121103Medicaid
TX139121108Medicaid
TX139121112Medicaid
TX139121101Medicaid
TX139121102Medicaid
TX139121113Medicaid
TX8U7231OtherBLUE CROSS BLUE SHIELD
TX139121105Medicaid
TX139121114Medicaid
TX139121104Medicaid
TX139121107Medicaid
TX139121109Medicaid
TX139121102Medicaid
TX86X878Medicare PIN