Healthcare Provider Details

I. General information

NPI: 1366676470
Provider Name (Legal Business Name): NEDSON JOHN CAMPBELL II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 HAYNES ST
MANCHESTER CT
06040-4131
US

IV. Provider business mailing address

71 HAYNES ST
MANCHESTER CT
06040-4131
US

V. Phone/Fax

Practice location:
  • Phone: 860-533-3434
  • Fax: 860-647-6829
Mailing address:
  • Phone: 860-533-3434
  • Fax: 860-647-6829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number050231
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number050231
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: