Provider Demographics
NPI:1700419736
Name:CAMPBELL, DEMERIOUS RAYSHAWN
Entity Type:Individual
Prefix:
First Name:DEMERIOUS
Middle Name:RAYSHAWN
Last Name:CAMPBELL
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 1:2946 AQUADALE LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-8002
Mailing Address - Country:US
Mailing Address - Phone:513-250-0121
Mailing Address - Fax:
Practice Address - Street 1:2946 AQUADALE LN
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-8002
Practice Address - Country:US
Practice Address - Phone:513-250-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRY615525172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver