Provider Demographics
NPI:1811978828
Name:CAMPBELL, RICARDO (PA)
Entity type:Individual
Prefix:MR
First Name:RICARDO
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:818-788-7343
Mailing Address - Fax:818-788-9453
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:SUITE 800
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-788-7343
Practice Address - Fax:818-788-9453
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PA202440Medicaid
R36541Medicare UPIN
CAWPA20244BMedicare ID - Type Unspecified