Provider Demographics
NPI:1225017148
Name:NEWELL, KIP L (OD)
Entity type:Individual
Prefix:DR
First Name:KIP
Middle Name:L
Last Name:NEWELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 W WYANDOT AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1348
Mailing Address - Country:US
Mailing Address - Phone:419-209-0540
Mailing Address - Fax:419-209-0518
Practice Address - Street 1:131 W WYANDOT AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1348
Practice Address - Country:US
Practice Address - Phone:419-209-0540
Practice Address - Fax:419-209-0540
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4617 / T1363152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2006895Medicaid
OH0794647Medicare PIN
OHU41566Medicare UPIN
OH2006895Medicaid
OH4977220001Medicare NSC
OHP00123321Medicare PIN
OH6497470001Medicare NSC
OH0794643Medicare PIN
OHP00881514Medicare PIN