=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396787933
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC SCOTT CAMPENOT D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2006
-----------------------------------------------------
Last Update Date | 04/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34800 BOB WILSON DR NMCSD
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92134-1098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-532-9327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5940 COWLES MOUNTAIN BLVD
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-1803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-278-8628
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 0102201131
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------