Healthcare Provider Details

I. General information

NPI: 1245468925
Provider Name (Legal Business Name): EVAN N NEWBOLT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 WEST 28TH AVE
PINE BLUFF AR
71603
US

IV. Provider business mailing address

3805 WEST 28TH AVE
PINE BLUFF AR
71603
US

V. Phone/Fax

Practice location:
  • Phone: 870-536-4100
  • Fax: 304-598-6928
Mailing address:
  • Phone: 870-536-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberE-8054
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: