Basic Information
| Provider Information | |||||||||
| NPI: | 1386081131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEWPORT MATRIX LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3022 S DURANGO DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891174439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022563637 | ||||||||
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| Address1: | 3022 S DURANGO DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891174439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022563637 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2013 | ||||||||
| LastUpdateDate: | 06/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | PHAM | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7023697886 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 11052 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.