Provider Demographics
NPI:1811301377
Name:CAMPBELL, JACOB DALE (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DALE
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:UCONN SCHOOL OF MEDICINE DEPT OF SURGERY
Mailing Address - Street 2:263 FARMINGTON AVE
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-3955
Mailing Address - Country:US
Mailing Address - Phone:860-679-2147
Mailing Address - Fax:860-679-4624
Practice Address - Street 1:UCONN SCHOOL OF MEDICINE DEPT OF SURGERY
Practice Address - Street 2:263 FARMINGTON AVE
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-3955
Practice Address - Country:US
Practice Address - Phone:860-679-2147
Practice Address - Fax:860-679-4624
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
CT754612086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program