Provider Demographics
NPI:1497720643
Name:NEWELL, GORDON B (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:B
Last Name:NEWELL
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 1:1320 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2556
Mailing Address - Country:US
Mailing Address - Phone:279-781-3880
Mailing Address - Fax:270-781-5351
Practice Address - Street 1:1320 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2556
Practice Address - Country:US
Practice Address - Phone:270-781-3880
Practice Address - Fax:270-781-5351
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17218174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64172182Medicaid
KY64172182Medicaid
KY1027601Medicare ID - Type Unspecified