Provider Demographics
NPI:1982653721
Name:CAMPBELL, JESSE R (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:R
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-755-1515
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:1575 N SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3638
Practice Address - Country:US
Practice Address - Phone:405-285-0660
Practice Address - Fax:405-285-0659
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2017-12-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK20229207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20229OtherLICENSE
OK100108140AMedicaid
OK25208OtherOBNDD
OKG85229Medicare UPIN
OK246633103Medicare PIN