Healthcare Provider Details

I. General information

NPI: 1083283642
Provider Name (Legal Business Name): MATTHEW B. NEWBOLD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 N TELSHOR BLVD
LAS CRUCES NM
88011-8230
US

IV. Provider business mailing address

2810 N TELSHOR BLVD
LAS CRUCES NM
88011-8230
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-2020
  • Fax: 575-521-1553
Mailing address:
  • Phone: 575-523-2020
  • Fax: 575-521-1553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.0003708
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT739
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: