Provider Demographics
NPI:1205940582
Name:CAMPBELL, JUAN (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 W 15TH ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1610
Mailing Address - Country:US
Mailing Address - Phone:773-257-1700
Mailing Address - Fax:773-257-6888
Practice Address - Street 1:2720 W 15TH ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1610
Practice Address - Country:US
Practice Address - Phone:773-257-1700
Practice Address - Fax:773-257-6888
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2012-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-109131208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI18367Medicare UPIN
367830Medicare PIN