Provider Demographics
NPI:1295890408
Name:CAMPOS, LUIS O
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:O
Last Name:CAMPOS
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 1:11054 E VIEUX DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-5285
Mailing Address - Country:US
Mailing Address - Phone:225-231-8030
Mailing Address - Fax:
Practice Address - Street 1:5760 MONTICELLO DRIVE
Practice Address - Street 2:
Practice Address - City:ST GABRIEL
Practice Address - State:LA
Practice Address - Zip Code:70776
Practice Address - Country:US
Practice Address - Phone:225-642-9676
Practice Address - Fax:225-642-9696
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA38601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1117226Medicaid
LA4B706D857Medicare PIN