Provider Demographics
NPI:1114934353
Name:CAMPBELL, C. E JR (MD, PA)
Entity Type:Individual
Prefix:
First Name:C.
Middle Name:E
Last Name:CAMPBELL
Suffix:JR
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-1922
Mailing Address - Country:US
Mailing Address - Phone:870-763-0855
Mailing Address - Fax:870-763-0858
Practice Address - Street 1:609 FULTON ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1922
Practice Address - Country:US
Practice Address - Phone:870-763-0855
Practice Address - Fax:870-763-0858
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR1755174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103439001Medicaid
AR508807299OtherMEDICARE RENDERING #
AR1104017227OtherGROUP NPI
AR1114934353OtherINDIVIDUAL NPI
MO201045309Medicaid
AR50880OtherINDIVIDUAL BC/BS
ARR1755OtherSTATE LICENSE
AR103439001Medicaid