Provider Demographics
NPI:1417042136
Name:CAMPOS, JUAN (MD)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:
Last Name:CAMPOS
Suffix:
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 1:110 S ANNISTON AVE
Mailing Address - Street 2:STE. 110
Mailing Address - City:SYLACAUGA
Mailing Address - State:AL
Mailing Address - Zip Code:35150-2961
Mailing Address - Country:US
Mailing Address - Phone:256-401-4070
Mailing Address - Fax:256-401-4603
Practice Address - Street 1:110 S ANNISTON AVE
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2961
Practice Address - Country:US
Practice Address - Phone:256-207-0200
Practice Address - Fax:256-207-0201
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00021307208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051523150Medicaid
AL051523150Medicaid
ALH13449Medicare UPIN