Provider Demographics
NPI:1720167356
Name:CAMPANELLA, JERRY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:A
Last Name:CAMPANELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:210 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10604-2901
Mailing Address - Country:US
Mailing Address - Phone:914-681-3146
Mailing Address - Fax:914-682-6403
Practice Address - Street 1:1254 CENTRAL PK AVENUE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10704
Practice Address - Country:US
Practice Address - Phone:914-965-1771
Practice Address - Fax:914-964-8336
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY202490207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01760118Medicaid
NY01760118Medicaid
NY440981Medicare ID - Type Unspecified