Provider Demographics
NPI:1790823961
Name:CAMPBELL, THEODORE A JR (DC)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:A
Last Name:CAMPBELL
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 GODWIN AVE
Mailing Address - Street 2:STE 8
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-2099
Mailing Address - Country:US
Mailing Address - Phone:201-327-3236
Mailing Address - Fax:201-327-3231
Practice Address - Street 1:260 GODWIN AVE
Practice Address - Street 2:STE 8
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-2099
Practice Address - Country:US
Practice Address - Phone:201-327-3236
Practice Address - Fax:201-327-3231
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1760111N00000X
PADC001854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0489000Medicaid
443046Medicare ID - Type Unspecified