Provider Demographics
NPI:1083283642
Name:NEWBOLD, MATTHEW B (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:NEWBOLD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 N TELSHOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8230
Mailing Address - Country:US
Mailing Address - Phone:575-523-2020
Mailing Address - Fax:575-521-1553
Practice Address - Street 1:2810 N TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8230
Practice Address - Country:US
Practice Address - Phone:575-523-2020
Practice Address - Fax:575-521-1553
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003708152W00000X
NMOPT739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM41383362Medicaid