Healthcare Provider Details

I. General information

NPI: 1831453711
Provider Name (Legal Business Name): D'CHRISTOPHER MONTRAE NEWTON CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3149 CASA DE CAMPO APT 107
SAN MATEO CA
94403-2155
US

IV. Provider business mailing address

3149 CASA DE CAMPO APT 107
SAN MATEO CA
94403-2155
US

V. Phone/Fax

Practice location:
  • Phone: 623-377-8187
  • Fax:
Mailing address:
  • Phone: 623-377-8187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License NumberD05596325
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: