Provider Demographics
NPI:1104860741
Name:CAMPBELL, JACK P (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:P
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:325-659-0180
Practice Address - Street 1:2626 N BRYANT BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903
Practice Address - Country:US
Practice Address - Phone:325-658-1511
Practice Address - Fax:325-481-2166
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXF6501207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CC616OtherBCBS
TX047231802Medicaid
TX8CC616OtherBCBS
TX8L20798Medicare PIN