=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528164928
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLYDE ALFRED NEWTON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 10/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 BELMONT AVE NO 101
-----------------------------------------------------
City | BRATTLEBORO
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-257-0110
-----------------------------------------------------
Fax | 802-257-0127
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 BELMONT AVE NO 101
-----------------------------------------------------
City | BRATTLEBORO
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-257-0110
-----------------------------------------------------
Fax | 802-257-0127
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 0420003916
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------