Provider Demographics
NPI:1235330432
Name:CAMPBELL, PETER GRAVEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:GRAVEL
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 1:1500 LINE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4643
Mailing Address - Country:US
Mailing Address - Phone:318-629-5555
Mailing Address - Fax:318-629-5556
Practice Address - Street 1:1500 LINE AVE STE 200
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4643
Practice Address - Country:US
Practice Address - Phone:318-629-5555
Practice Address - Fax:318-629-5556
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA301918207T00000X
PAMD445855207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA243409M0TMedicare PIN
MD243411YQUMedicare PIN
MD243411YQUMedicare PIN