Provider Demographics
NPI:1912913179
Name:CAMPBELL, DENNIS B (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:B
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:KY
Mailing Address - Zip Code:41365-0002
Mailing Address - Country:US
Mailing Address - Phone:606-668-9915
Mailing Address - Fax:606-668-3016
Practice Address - Street 1:3830 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-8675
Practice Address - Country:US
Practice Address - Phone:606-668-7420
Practice Address - Fax:606-668-7404
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY263202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000225374OtherANTHEM BCBS
KY30610026Medicaid
10979OtherCHA
11676152OtherCAQH
279406OtherMANAGED HEALTH
000000225374OtherANTHEM BCBS
KY30610026Medicaid
11676152OtherCAQH
KY45303849Medicare ID - Type UnspecifiedKMAP EPSDT
0520102Medicare ID - Type UnspecifiedMONTGOMERY CO