Provider Demographics
NPI:1053300210
Name:NEWBERRY, GARY W (DC)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:W
Last Name:NEWBERRY
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 1:1619 6TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4605
Mailing Address - Country:US
Mailing Address - Phone:863-297-5250
Mailing Address - Fax:863-299-1315
Practice Address - Street 1:1619 6TH ST SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4605
Practice Address - Country:US
Practice Address - Phone:863-297-5250
Practice Address - Fax:863-299-1315
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH2738111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0511331-00Medicaid
FL88152ZMedicare ID - Type Unspecified
FLT55715Medicare UPIN