Provider Demographics
NPI:1407821432
Name:CAMPBELL, DOLLY ANN (OD)
Entity type:Individual
Prefix:DR
First Name:DOLLY
Middle Name:ANN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4437
Mailing Address - Country:US
Mailing Address - Phone:618-993-5686
Mailing Address - Fax:618-997-6250
Practice Address - Street 1:1207 N ONE MILE RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1041
Practice Address - Country:US
Practice Address - Phone:573-624-4584
Practice Address - Fax:573-624-4585
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO205031543152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0814870002OtherMEDICARE NSC NUMBER
MO317565307Medicaid
137071OtherHEALTH ALLIANCE
MOP00418700 CI6575OtherMEDICARE RAILROAD
MO220392OtherANTHEM BLUE CROSS BLUE SHIELD
MO1543OtherEYEMED
MO0814870006OtherMEDICARE NSC NUMBER
MO0814870015OtherMEDICARE NSC NUMBER
MO0814870017OtherMEDICARE NSC NUMBER
IL$$$$$$$$$Medicaid
MO0814870002OtherMEDICARE NSC NUMBER
MOV07251Medicare UPIN