Healthcare Provider Details

I. General information

NPI: 1649705799
Provider Name (Legal Business Name): T LYDEL NEWSOME
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11886 HEALING WAY
SILVER SPRING MD
20904-7917
US

IV. Provider business mailing address

2401 W BELVEDERE AVE
BALTIMORE MD
21215-5216
US

V. Phone/Fax

Practice location:
  • Phone: 301-608-3833
  • Fax:
Mailing address:
  • Phone: 410-601-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD89605
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: