Provider Demographics
NPI:1932566130
Name:NEWTON, VIRGIL ALLEN (DIVE IDC)
Entity Type:Individual
Prefix:
First Name:VIRGIL
Middle Name:ALLEN
Last Name:NEWTON
Suffix:
Gender:M
Credentials:DIVE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4643 DOCK RD BLDG 524
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93043-4321
Mailing Address - Country:US
Mailing Address - Phone:805-982-6682
Mailing Address - Fax:805-982-3246
Practice Address - Street 1:4643 DOCK RD BLDG 524
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93043-4321
Practice Address - Country:US
Practice Address - Phone:805-982-6682
Practice Address - Fax:805-982-3246
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman