Provider Demographics
NPI:1306938592
Name:CAMPBELL, ANNYCE RAMONA (MD)
Entity type:Individual
Prefix:DR
First Name:ANNYCE
Middle Name:RAMONA
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANNYCE
Other - Middle Name:RAMONA
Other - Last Name:CAMPBELL-BULTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4510 HANGING MOSS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-3962
Mailing Address - Country:US
Mailing Address - Phone:769-257-5713
Mailing Address - Fax:769-257-5715
Practice Address - Street 1:4510 HANGING MOSS RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3962
Practice Address - Country:US
Practice Address - Phone:769-257-5713
Practice Address - Fax:769-257-5715
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00012698Medicaid
MS251936Medicare Oscar/Certification
MS251850Medicare Oscar/Certification
MS080000062Medicare PIN
MS251933Medicare Oscar/Certification
MS00012698Medicaid
MSD00892Medicare UPIN