Healthcare Provider Details

I. General information

NPI: 1194902510
Provider Name (Legal Business Name): GARY HUBERT CAMPBELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CONWAY SPRINGS DR
CHESTERFIELD MO
63017-3411
US

IV. Provider business mailing address

21 CONWAY SPRINGS DR
CHESTERFIELD MO
63017-3411
US

V. Phone/Fax

Practice location:
  • Phone: 314-514-0354
  • Fax: 314-579-6083
Mailing address:
  • Phone: 314-514-0354
  • Fax: 314-579-6083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number33535
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: