Provider Demographics
NPI:1710088711
Name:CAMPBELL, JEREMY SHANE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:SHANE
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14378 HIGHWAY 43
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-2568
Mailing Address - Country:US
Mailing Address - Phone:256-332-1355
Mailing Address - Fax:256-332-1315
Practice Address - Street 1:14378 HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-2568
Practice Address - Country:US
Practice Address - Phone:256-332-1355
Practice Address - Fax:256-332-1315
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-A80-TA-660152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529930260Medicaid
AL009940024Medicaid
AL009940024Medicaid
AL051537331Medicare PIN
ALV05239Medicare UPIN
AL6037280001Medicare NSC