Provider Demographics
NPI:1356446314
Name:CAMPBELL, DEREK ALLEN (PHD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ALLEN
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 AURORA AVE STE 202W
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-2876
Mailing Address - Country:US
Mailing Address - Phone:515-252-2522
Mailing Address - Fax:515-252-2523
Practice Address - Street 1:6200 AURORA AVE STE 202W
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-2876
Practice Address - Country:US
Practice Address - Phone:515-252-2522
Practice Address - Fax:515-252-2523
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00899103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIA16725Medicare UPIN