Provider Demographics
NPI:1902966161
Name:SCHULSTAD, CAMPBELL KARL (MD)
Entity Type:Individual
Prefix:
First Name:CAMPBELL
Middle Name:KARL
Last Name:SCHULSTAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 KY HIGHWAY 36 E
Mailing Address - Street 2:SUITE G3
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-7490
Mailing Address - Country:US
Mailing Address - Phone:859-235-3638
Mailing Address - Fax:859-235-3536
Practice Address - Street 1:1210 KY HIGHWAY 36 E
Practice Address - Street 2:SUITE 1D
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-7490
Practice Address - Country:US
Practice Address - Phone:859-234-1707
Practice Address - Fax:859-234-1768
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30180208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64018039Medicaid
F76284Medicare UPIN
KY64018039Medicaid