Provider Demographics
NPI:1114272317
Name:NEWSOME, JELAUN KEITH (DO)
Entity type:Individual
Prefix:DR
First Name:JELAUN
Middle Name:KEITH
Last Name:NEWSOME
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LRMC
Mailing Address - Street 2:UNIT 33100
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LRMC
Practice Address - Street 2:UNIT 33100
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180
Practice Address - Country:US
Practice Address - Phone:314-590-4913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1103207Q00000X, 2083X0100X, 2083A0100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program