Provider Demographics
NPI:1184761207
Name:CAMPERLENGO, NICHOLAS V
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:V
Last Name:CAMPERLENGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 BROOKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-2761
Mailing Address - Country:US
Mailing Address - Phone:817-932-0102
Mailing Address - Fax:
Practice Address - Street 1:616 W RUSSELL PL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3658
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK52652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117211603Medicaid
TX89412GOtherBLUE CROSS BLUE SHIELD
TX117211602Medicaid
TX117211601Medicaid
TX82121KMedicare ID - Type UnspecifiedTARRANT COUNTY
TX117211601Medicaid
TX89412GOtherBLUE CROSS BLUE SHIELD