Provider Demographics
NPI:1467510693
Name:CAMPBELL, OTIS JR (MD)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:
Last Name:CAMPBELL
Suffix:JR
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:PO BOX 280956
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37228-0956
Mailing Address - Country:US
Mailing Address - Phone:615-327-0338
Mailing Address - Fax:615-320-0668
Practice Address - Street 1:3109 JOHN A MERRITT BLVD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-1509
Practice Address - Country:US
Practice Address - Phone:615-320-0338
Practice Address - Fax:615-320-0668
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD018561174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNBC2330811OtherDEA
TNBC2330811OtherDEA
TNE09549Medicare UPIN