Provider Demographics
NPI:1811458896
Name:CAMPBELL, JOHNNY JR
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:CAMPBELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 W D. L. INGRAM AVENUE, BLDG. 1408
Mailing Address - Street 2:
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103-3634
Mailing Address - Country:US
Mailing Address - Phone:759-043-8485
Mailing Address - Fax:
Practice Address - Street 1:224 W D. L. INGRAM AVENUE, BLDG. 1408
Practice Address - Street 2:
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:575-904-3848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA329391207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program