Healthcare Provider Details

I. General information

NPI: 1871112862
Provider Name (Legal Business Name): LARRY MICHAEL NEWTON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 08/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

13951 GROVE PATCH
SAN ANTONIO TX
78247-3190
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-3397
  • Fax:
Mailing address:
  • Phone: 210-287-0623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberU6034
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: