MEDICARE: JOHNNY CAMPBELL JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	93960	SC
2	207Q00000X	Family Medicine Physician	329391	LA

General Provider Information

NPI Number	:	1811458896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNNY CAMPBELL JR.

Provider Business Mailing Address
First Line	:	224 W D. L. INGRAM AVENUE, BLDG. 1408
Second Line	:
City	:	CANNON AFB
State	:	NM
Zip	:	88103-3634
Country	:	US
Telephone Number	:	759-043-8485
Fax Number	:

Provider Business Practice Location Address
First Line	:	317 SAINT FRANCIS DR STE 220
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-3976
Country	:	US
Telephone Number	:	864-255-1901
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2019
Last Update Date	:	07/24/2025

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