Provider Demographics
NPI:1992791560
Name:NEWSOM, JEFFREY A (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:NEWSOM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:42D MEDICAL GROUP
Mailing Address - Street 2:300 S. TWINING ST, BLDG 760
Mailing Address - City:MAXWELL AFB
Mailing Address - State:AL
Mailing Address - Zip Code:36112-6027
Mailing Address - Country:US
Mailing Address - Phone:334-953-5200
Mailing Address - Fax:877-813-1756
Practice Address - Street 1:42D MEDICAL GROUP
Practice Address - Street 2:300 S. TWINING ST, BLDG 760
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112-6027
Practice Address - Country:US
Practice Address - Phone:334-953-5200
Practice Address - Fax:877-813-1756
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT771152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare UPIN