Provider Demographics
NPI:1225078983
Name:NEWMAN, THEODORE W (OD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:W
Last Name:NEWMAN
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:PO BOX 1956
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1956
Mailing Address - Country:US
Mailing Address - Phone:843-332-7171
Mailing Address - Fax:843-332-7802
Practice Address - Street 1:504 S 4TH ST
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-5720
Practice Address - Country:US
Practice Address - Phone:843-332-7171
Practice Address - Fax:843-332-7802
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC668152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC459665Medicaid
SC459665Medicaid