Provider Demographics
NPI:1215915012
Name:NEWMAN, JACK NATHANIEL JR (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:NATHANIEL
Last Name:NEWMAN
Suffix:JR
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 1:3903 BRIAR KNOLL CIR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-2132
Mailing Address - Country:US
Mailing Address - Phone:919-630-1616
Mailing Address - Fax:
Practice Address - Street 1:3903 BRIAR KNOLL CIR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:MD
Practice Address - Zip Code:21131-2132
Practice Address - Country:US
Practice Address - Phone:919-630-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99-01450207RC0000X
KY48806207RC0000X
MDD75445207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG11700Medicare UPIN
NCG11700Medicare UPIN