Basic Information
| Provider Information | |||||||||
| NPI: | 1437528742 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEWSOM EYE & LASER CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13904 N DALE MABRY HWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336182446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139082020 | ||||||||
| FaxNumber: | 8139082133 | ||||||||
| Practice Location | |||||||||
| Address1: | 13904 N DALE MABRY HWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336182446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139082020 | ||||||||
| FaxNumber: | 8139082133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2015 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | NEWSOM | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | HUNTER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8139082020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NEWSOM EYE & LASER CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 271214804 | 05 | FL | MEDICAID | 271214802 | 05 | FL | MEDICAID |