Provider Demographics
NPI:1790388734
Name:NEWARK, KEVIN DAVID
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DAVID
Last Name:NEWARK
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 1:6100 LAURENT DR APT 709
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5965
Mailing Address - Country:US
Mailing Address - Phone:216-339-9664
Mailing Address - Fax:
Practice Address - Street 1:6100 LAURENT DR APT 709
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44129-5965
Practice Address - Country:US
Practice Address - Phone:216-339-9664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1831346376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1831346Medicaid