1679680052 NPI number — DR. JACK RONALD NEWTON MD

Table of content: DR. JACK RONALD NEWTON MD (NPI 1679680052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679680052 NPI number — DR. JACK RONALD NEWTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEWTON
Provider First Name:
JACK
Provider Middle Name:
RONALD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679680052
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8019 DIXIE HWY SUITE 101
Provider Second Line Business Mailing Address:
JENCARE NEIGHBORHOOD MEDICAL VALLEY STATION, LLC
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-333-3121
Provider Business Mailing Address Fax Number:
502-333-3131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2526 WESLEYAN PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42301-5430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-929-6608
Provider Business Practice Location Address Fax Number:
502-333-3131
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  174400000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 18927 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 18927 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64189277 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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