Provider Demographics
NPI:1043378631
Name:CAMPO, BRIAN (LAC DIPL OM NCCAOM)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:CAMPO
Suffix:
Gender:M
Credentials:LAC DIPL OM NCCAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 50 WATERS EDGE DRIVE
Mailing Address - Street 2:APT 5J
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360
Mailing Address - Country:US
Mailing Address - Phone:718-352-0698
Mailing Address - Fax:718-229-4983
Practice Address - Street 1:213 15 33RD ROAD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361
Practice Address - Country:US
Practice Address - Phone:718-229-4578
Practice Address - Fax:718-229-4983
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002729171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist