Provider Demographics
NPI:1154387967
Name:CAMPBELL, RICHARD A (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
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 1:105 TOMOKA BLVD S
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-8123
Mailing Address - Country:US
Mailing Address - Phone:863-465-7010
Mailing Address - Fax:863-465-7266
Practice Address - Street 1:105 TOMOKA BLVD S
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-8123
Practice Address - Country:US
Practice Address - Phone:863-465-7010
Practice Address - Fax:863-465-7266
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28093OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL064369600Medicaid
28093XMedicare PIN
28093WMedicare PIN
28093VMedicare PIN
FLD53478Medicare UPIN
FL28093OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL28093Medicare PIN