Provider Demographics
NPI:1912499328
Name:NEWBERRY, CHARLES FRED III (DOM)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:FRED
Last Name:NEWBERRY
Suffix:III
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 1/2 CAMINO CERRITO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5912
Mailing Address - Country:US
Mailing Address - Phone:505-216-0864
Mailing Address - Fax:
Practice Address - Street 1:1446 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4038
Practice Address - Country:US
Practice Address - Phone:505-690-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1225171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist