Basic Information
Provider Information | |||||||||
NPI: | 1326373598 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERRY | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ACOSTA | ||||||||
OtherFirstName: | LORI | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2102 TREASURE HILLS BLVD. | ||||||||
Address2: | #3.144.06 | ||||||||
City: | HARLINGEN | ||||||||
State: | TX | ||||||||
PostalCode: | 785508736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9562961437 | ||||||||
FaxNumber: | 9562966842 | ||||||||
Practice Location | |||||||||
Address1: | 1102 W TRENTON RD | ||||||||
Address2: |   | ||||||||
City: | EDINBURG | ||||||||
State: | TX | ||||||||
PostalCode: | 785399105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9564512316 | ||||||||
FaxNumber: | 9562966851 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2009 | ||||||||
LastUpdateDate: | 02/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | FTL46605 | TX | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 392864001 | 05 | TX |   | MEDICAID | H08KQ93201 | 01 | TX | BCBS | OTHER |