Provider Demographics
NPI:1366425027
Name:CAMPOS, LUIS ISMAEL (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ISMAEL
Last Name:CAMPOS
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 1:101 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-6704
Mailing Address - Country:US
Mailing Address - Phone:610-821-9228
Mailing Address - Fax:
Practice Address - Street 1:101 S 17TH ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-6704
Practice Address - Country:US
Practice Address - Phone:610-821-9228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038866L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0000960429Medicaid
PA094108Medicare ID - Type Unspecified
PAC29700Medicare UPIN