Provider Demographics
NPI:1366676470
Name:CAMPBELL, NEDSON JOHN II (MD)
Entity Type:Individual
Prefix:DR
First Name:NEDSON
Middle Name:JOHN
Last Name:CAMPBELL
Suffix:II
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 1:71 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4131
Mailing Address - Country:US
Mailing Address - Phone:860-533-3434
Mailing Address - Fax:860-647-6829
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-533-3434
Practice Address - Fax:860-647-6829
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0502312084P0802X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004041000Medicaid
CT008003745Medicaid
CT008042339Medicaid
CTD400092056OtherPTAN GROUP MEMBER NUMBER
CT008022622Medicaid
CT008045321Medicaid
CT004082260Medicaid
CT008022626Medicaid
CTC01033OtherAPT PTAN MEDICARE
CT004217099Medicaid
CT008001325Medicaid
CT008023170Medicaid
CT008024427Medicaid
CT004025177Medicaid
CT004082286Medicaid
CT008039745Medicaid
CT500000315Medicaid
CTD400092056OtherPTAN GROUP MEMBER NUMBER
CT004217099Medicaid
CTD400154886Medicare PIN