Provider Demographics
NPI:1932389640
Name:NEWCOMER, MARK D (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:NEWCOMER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:IL
Mailing Address - Zip Code:61036-1902
Mailing Address - Country:US
Mailing Address - Phone:815-777-0042
Mailing Address - Fax:815-777-0043
Practice Address - Street 1:400 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-1902
Practice Address - Country:US
Practice Address - Phone:815-777-0042
Practice Address - Fax:815-777-0043
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37429Medicare UPIN
IL644160Medicare PIN