Provider Demographics
NPI:1659302370
Name:CAMPBELL, LARRY L (DO)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11129 74TH ST
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:KS
Mailing Address - Zip Code:66066-5394
Mailing Address - Country:US
Mailing Address - Phone:785-863-2882
Mailing Address - Fax:785-863-4135
Practice Address - Street 1:313 JEFFERSON
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:KS
Practice Address - Zip Code:66066
Practice Address - Country:US
Practice Address - Phone:785-863-4125
Practice Address - Fax:785-863-4135
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-21655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSD17402Medicare UPIN
KS103116Medicare ID - Type UnspecifiedOMC