Provider Demographics
NPI:1710980784
Name:CAMPELL, EDWARD SIDNEY (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:SIDNEY
Last Name:CAMPELL
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 1:94 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08618-1611
Mailing Address - Country:US
Mailing Address - Phone:609-883-5083
Mailing Address - Fax:815-572-5075
Practice Address - Street 1:94 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08618-1611
Practice Address - Country:US
Practice Address - Phone:609-883-5083
Practice Address - Fax:815-572-5075
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2012-08-17
Deactivation Date:2010-04-08
Deactivation Code:
Reactivation Date:2012-08-17
Provider Licenses
StateLicense IDTaxonomies
NJ270A00276400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2584506Medicaid
NJU12967Medicare UPIN
NJ2584506Medicaid