Provider Demographics
NPI:1790812204
Name:CAMPBELL, KURT W (OCT)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:W
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:OCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 SOUTHAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154-1205
Mailing Address - Country:US
Mailing Address - Phone:215-965-0326
Mailing Address - Fax:215-965-0377
Practice Address - Street 1:2701 SOUTHAMPTON RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19154-1205
Practice Address - Country:US
Practice Address - Phone:215-965-0326
Practice Address - Fax:215-965-0377
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC004123L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist