Provider Demographics
NPI:1093172926
Name:CAMPBELL, BRYAN ROY (DO)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ROY
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93246-4700
Mailing Address - Country:US
Mailing Address - Phone:559-998-4384
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR BLDG 3-4TH
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-916-1686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-22
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204987208600000X, 208D00000X, 390200000X
CA17802208D00000X, 390200000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program