Provider Demographics
NPI:1265642664
Name:SUSAN D MENCARINI & JAY A NEWSOME
Entity Type:Organization
Organization Name:SUSAN D MENCARINI & JAY A NEWSOME
Other - Org Name:JAY A NEWSOME OD & SUSAN D MENCARINI OD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:559-298-2120
Mailing Address - Street 1:145 N CLOVIS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0361
Mailing Address - Country:US
Mailing Address - Phone:559-298-2120
Mailing Address - Fax:559-299-3741
Practice Address - Street 1:145 N CLOVIS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0361
Practice Address - Country:US
Practice Address - Phone:559-298-2120
Practice Address - Fax:559-299-3741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA09054T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0506780001Medicare NSC