Provider Demographics
NPI:1134139975
Name:NEWSOM, ROGER W (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:W
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 1:1788 GREENSWARD QUAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1141
Mailing Address - Country:US
Mailing Address - Phone:757-496-3982
Mailing Address - Fax:
Practice Address - Street 1:3235 ACADEMY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3200
Practice Address - Country:US
Practice Address - Phone:757-483-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055448207W00000X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA325053OtherANTHEM
VA325053OtherANTHEM
VAG46672Medicare UPIN
180000765Medicare PIN