Healthcare Provider Details

I. General information

NPI: 1023198280
Provider Name (Legal Business Name): JUAN IGNACIO CAMPOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16019 VIA SHAVANO
SAN ANTONIO TX
78249-2370
US

IV. Provider business mailing address

16019 VIA SHAVANO
SAN ANTONIO TX
78249-2370
US

V. Phone/Fax

Practice location:
  • Phone: 210-696-9292
  • Fax: 210-690-8815
Mailing address:
  • Phone: 210-696-9292
  • Fax: 210-690-8815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberK8047
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License NumberK8047
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: