Provider Demographics
NPI:1407908395
Name:CAMPODONICO, JEFFREY (PHD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:CAMPODONICO
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 1:120 SISTER PIERRE DR
Mailing Address - Street 2:SUITE 501
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-7516
Mailing Address - Country:US
Mailing Address - Phone:410-598-4966
Mailing Address - Fax:410-337-8686
Practice Address - Street 1:120 SISTER PIERRE DR
Practice Address - Street 2:SUITE 501
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7516
Practice Address - Country:US
Practice Address - Phone:410-337-6801
Practice Address - Fax:410-337-8686
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2009-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3071103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD706MOtherMEDICARE GROUP ID NO.
MDKEJ2JEOtherBCBS PREFERRED PROVIDER
MD403513500Medicaid
MD706MOtherMEDICARE GROUP ID NO.