Provider Demographics
NPI:1689617797
Name:NEWTON, DIANE R (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:R
Last Name:NEWTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23625 COMMERCE PARK
Mailing Address - Street 2:#204
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5845
Mailing Address - Country:US
Mailing Address - Phone:216-255-5743
Mailing Address - Fax:866-735-3451
Practice Address - Street 1:2035 SILVERCREEK LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6112
Practice Address - Country:US
Practice Address - Phone:208-368-0095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM72782085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD223007100Medicaid
OH2914252Medicaid
ID804198300Medicaid
LA1452114Medicaid
SCQM7278Medicaid
1689617797OtherTRICARE NORTH
ID804198300Medicaid
ID11239165Medicare PIN
LA1452114Medicaid
ID11378071Medicare PIN