Provider Demographics
NPI:1275623183
Name:NEWBORN, ODIE VERNON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ODIE
Middle Name:VERNON
Last Name:NEWBORN
Suffix:JR
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 1:400 E PARADISE LN
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-4142
Mailing Address - Country:US
Mailing Address - Phone:928-575-6643
Mailing Address - Fax:
Practice Address - Street 1:12033 AGENCY RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-7718
Practice Address - Country:US
Practice Address - Phone:928-669-3300
Practice Address - Fax:928-669-3131
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11546207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020537Medicaid
AZAZ0201750OtherAZ BC/BS
AZAZ0201750OtherAZ BC/BS
TND30342Medicare UPIN
AZ020537Medicaid