Healthcare Provider Details

I. General information

NPI: 1073908893
Provider Name (Legal Business Name): THALMON RUELA CAMPAGNOLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 PRIMERA BLVD
LAKE MARY FL
32746-2175
US

IV. Provider business mailing address

95 COLUMBIA ST
ORLANDO FL
32806-1101
US

V. Phone/Fax

Practice location:
  • Phone: 407-333-1570
  • Fax: 407-333-1381
Mailing address:
  • Phone: 407-849-9621
  • Fax: 407-367-6346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME169828
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberME169828
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: