Provider Demographics
NPI:1174616635
Name:CAMPBELL, JOHN D (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:CAMPBELL
Suffix:
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:PO BOX 741
Mailing Address - Street 2:
Mailing Address - City:POLK CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33868-0471
Mailing Address - Country:US
Mailing Address - Phone:863-967-7744
Mailing Address - Fax:863-967-7848
Practice Address - Street 1:529 BERKLEY ROAD
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823
Practice Address - Country:US
Practice Address - Phone:863-967-7744
Practice Address - Fax:863-967-7848
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0034315207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04212Medicare ID - Type UnspecifiedMEDICARE NUMBER
FLD61036Medicare UPIN