Provider Demographics
NPI:1346213261
Name:CAMPBELL, KENT A (DO)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:A
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12255 DE PAUL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12255 DE PAUL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2510
Practice Address - Country:US
Practice Address - Phone:314-344-7600
Practice Address - Fax:314-344-7850
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMOR1E21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00035726OtherRAILROAD MEDICARE
MOA10564Medicare UPIN