1407908395 NPI number — JEFFREY CAMPODONICO PH.D.

Table of content: JEFFREY CAMPODONICO PH.D. (NPI 1407908395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407908395 NPI number — JEFFREY CAMPODONICO PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMPODONICO
Provider First Name:
JEFFREY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407908395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 SISTER PIERRE DR
Provider Second Line Business Mailing Address:
SUITE 501
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21204-7516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-598-4966
Provider Business Mailing Address Fax Number:
410-337-8686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 SISTER PIERRE DR
Provider Second Line Business Practice Location Address:
SUITE 501
Provider Business Practice Location Address City Name:
TOWSON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21204-7516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-337-6801
Provider Business Practice Location Address Fax Number:
410-337-8686
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  3071 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 706M . This is a "MEDICARE GROUP ID NO." identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: KEJ2JE . This is a "BCBS PREFERRED PROVIDER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 403513500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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