Provider Demographics
NPI:1740627942
Name:CAMPANA, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:CAMPANA
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 1:2914 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1332
Mailing Address - Country:US
Mailing Address - Phone:716-875-6700
Mailing Address - Fax:716-875-6853
Practice Address - Street 1:2914 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1332
Practice Address - Country:US
Practice Address - Phone:716-875-6700
Practice Address - Fax:716-875-6853
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY283025207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04492375Medicaid
NY539173001OtherBC/BS
NY539173001OtherBC/BS