Provider Demographics
NPI:1487677548
Name:CAMPOS-DE-LA-BORBOLLA, LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:
Last Name:CAMPOS-DE-LA-BORBOLLA
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:PO BOX 1000
Mailing Address - Street 2:DEPT # 457
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-516-0929
Mailing Address - Fax:901-516-8993
Practice Address - Street 1:1265 UNION AVE
Practice Address - Street 2:SUITE 184
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3415
Practice Address - Country:US
Practice Address - Phone:901-516-0929
Practice Address - Fax:901-516-8993
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060736208600000X
TN44107208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00873097Medicaid
TNQ002436Medicaid
TN4355465OtherBCBS
AR170500001Medicaid
TN103I027119Medicare PIN
MD403472400Medicaid
MD82498OtherGEISINGER
DC03607110Medicaid
DE1000034058Medicaid
MD0089OtherCAREFIRST REGIONAL