Provider Demographics
NPI:1508929480
Name:NEWSOM, GORDON C (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:C
Last Name:NEWSOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2350 ROYAL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4719
Mailing Address - Country:US
Mailing Address - Phone:847-695-8100
Mailing Address - Fax:847-695-6808
Practice Address - Street 1:2350 ROYAL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4719
Practice Address - Country:US
Practice Address - Phone:847-695-8100
Practice Address - Fax:847-695-6808
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036097435207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097435Medicaid
IL587210Medicare ID - Type Unspecified
ILG80580Medicare UPIN