Healthcare Provider Details

I. General information

NPI: 1235694381
Provider Name (Legal Business Name): JONATHAN MICHAEL CAMPBELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2019
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR # B7500
FT CARSON CO
80913-4613
US

IV. Provider business mailing address

1650 COCHRANE CIR # B7500
FT CARSON CO
80913-4613
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-2092
  • Fax: 719-526-7732
Mailing address:
  • Phone: 719-526-2092
  • Fax: 719-526-7732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number32938
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number32938
License Number StateNE

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: