Provider Demographics
NPI:1457441743
Name:MARTIN-DEL-CAMPO, HENRY
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:MARTIN-DEL-CAMPO
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 1:435 MAXINE DR
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2498
Mailing Address - Country:US
Mailing Address - Phone:309-263-2424
Mailing Address - Fax:309-284-2255
Practice Address - Street 1:435 MAXINE DR
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2498
Practice Address - Country:US
Practice Address - Phone:309-263-2424
Practice Address - Fax:309-284-2255
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-062779207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00622434OtherRR MEDICARE
CA2182OtherRR MEDICARE GROUP #
IL0360562779Medicaid
IL833230OtherGROUP # FOR PONTIAC
R01919Medicare PIN
F03411Medicare UPIN
IL833230OtherGROUP # FOR PONTIAC
ILL68715Medicare ID - Type UnspecifiedINDIVIDUAL #
ILCA4079Medicare ID - Type UnspecifiedRR GROUP #
CA2182OtherRR MEDICARE GROUP #