Provider Demographics
NPI:1306835947
Name:CAMPO, IVON (M)
Entity Type:Individual
Prefix:
First Name:IVON
Middle Name:
Last Name:CAMPO
Suffix:
Gender:M
Credentials:M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 W ORANGE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3159
Mailing Address - Country:US
Mailing Address - Phone:714-527-1262
Mailing Address - Fax:
Practice Address - Street 1:3055 W ORANGE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3159
Practice Address - Country:US
Practice Address - Phone:714-527-1262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC43138174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A348130Medicaid
CA00A348130Medicaid