Provider Demographics
NPI:1417149923
Name:CAMPBELL, DERRICK
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 SETON CENTER PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5295
Mailing Address - Country:US
Mailing Address - Phone:512-439-1000
Mailing Address - Fax:512-439-1081
Practice Address - Street 1:4700 SETON CENTER PKWY
Practice Address - Street 2:STE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5295
Practice Address - Country:US
Practice Address - Phone:512-439-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1169401OtherLICENSE#
TX1169401OtherLICENSE#
TX8L6012Medicare PIN
TX8L26831Medicare PIN
TX8L26645Medicare PIN