Basic Information
Provider Information | |||||||||
NPI: | 1154436632 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NEWSOM | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4102 AQUA VERDE DR. | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787461017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4325222304 | ||||||||
FaxNumber: | 4325222307 | ||||||||
Practice Location | |||||||||
Address1: | 4200 W ILLINOIS AVE | ||||||||
Address2: | SUITE 140 | ||||||||
City: | MIDLAND | ||||||||
State: | TX | ||||||||
PostalCode: | 797035692 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4325222304 | ||||||||
FaxNumber: | 4325222307 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2006 | ||||||||
LastUpdateDate: | 03/23/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | G5429 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RN0300X | G5429 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | P00199641 | 01 |   | RAILROAD MEDICARE | OTHER | 127799806 | 05 | TX |   | MEDICAID | 1277998-06 | 05 | TX |   | MEDICAID |