Provider Demographics
NPI:1588661904
Name:CAMPONOVO, ERNEST JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:JOHN
Last Name:CAMPONOVO
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 1:3700 PARK EAST DRIVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4305
Mailing Address - Country:US
Mailing Address - Phone:855-292-1401
Mailing Address - Fax:866-393-8340
Practice Address - Street 1:3700 PARK EAST DRIVE
Practice Address - Street 2:SUITE 450
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4305
Practice Address - Country:US
Practice Address - Phone:855-292-1401
Practice Address - Fax:866-393-8340
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042369L174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1588661904Medicaid
CA1588661904Medicaid
PA0012389070048Medicaid
FL003566900Medicaid
KY7100356790Medicaid
DC057342600Medicaid
MD470001500Medicaid
CAG88056OtherMEDICAL LICENSE
PA166787YA6CMedicare PIN
PA671091Medicare ID - Type Unspecified
CA1588661904Medicaid
PA671091V29Medicare PIN