Provider Demographics
NPI:1225007883
Name:CAMPOS, JAIME ENRIQUE
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:ENRIQUE
Last Name:CAMPOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 WEST 20TH AVENUE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016
Mailing Address - Country:US
Mailing Address - Phone:305-556-1544
Mailing Address - Fax:305-556-2025
Practice Address - Street 1:7100 WEST 20TH AVENUE
Practice Address - Street 2:SUITE 303
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016
Practice Address - Country:US
Practice Address - Phone:305-556-1544
Practice Address - Fax:305-556-2025
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME27911174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039126300Medicaid
FL039126300Medicaid
FL95219ZMedicare PIN