Provider Demographics
NPI:1942218763
Name:NEWTOWN SPORTS PODIATRY
Entity Type:Organization
Organization Name:NEWTOWN SPORTS PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:FULLEM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-426-7060
Mailing Address - Street 1:54 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-2358
Mailing Address - Country:US
Mailing Address - Phone:203-426-7060
Mailing Address - Fax:203-270-0420
Practice Address - Street 1:54 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-2358
Practice Address - Country:US
Practice Address - Phone:203-426-7060
Practice Address - Fax:203-270-0420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000556213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004112851Medicaid
CTU19859Medicare UPIN
CT6085810001Medicare NSC