Provider Demographics
NPI:1790956118
Name:JEFFREY R. CAMPODONICO, PH.D., P.A.
Entity Type:Organization
Organization Name:JEFFREY R. CAMPODONICO, PH.D., P.A.
Other - Org Name:NEUROHEALTH CONSULTING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:RUDOLPH
Authorized Official - Last Name:CAMPODONICO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-337-6801
Mailing Address - Street 1:529 PICCADILLY RD
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-3716
Mailing Address - Country:US
Mailing Address - Phone:410-598-4966
Mailing Address - Fax:410-337-8686
Practice Address - Street 1:120 SISTER PIERRE DR
Practice Address - Street 2:SUITE 501
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7516
Practice Address - Country:US
Practice Address - Phone:410-337-6801
Practice Address - Fax:410-337-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3071103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKEJ2OtherBLUECROSS/BLUE SHIELD
MD706MMedicare PIN