Provider Demographics
NPI:1467981035
Name:NEWSOME, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:NEWSOME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 N AZUSA AVE
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-3439
Mailing Address - Country:US
Mailing Address - Phone:626-731-5459
Mailing Address - Fax:
Practice Address - Street 1:135 RIO ROBLES E UNIT 165
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-1682
Practice Address - Country:US
Practice Address - Phone:626-731-5459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000255442255A2300X
CA36083111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA15421277OtherCAQH