Provider Demographics
NPI:1093746166
Name:NEWSOM, PETER EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:EDWARD
Last Name:NEWSOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1692 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-5208
Mailing Address - Country:US
Mailing Address - Phone:650-817-9070
Mailing Address - Fax:
Practice Address - Street 1:1692 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-5208
Practice Address - Country:US
Practice Address - Phone:650-817-9070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0657662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F36191Medicare UPIN
CA00G657660Medicare ID - Type Unspecified