Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 017472 | LA |
NPI | 1003847369 |
---|---|
Provider Name | Dr. Brent Oliver Campanella |
First Address | Baton Rouge, LA 70809-3541 |
Second Address | Baton Rouge, LA 70809-3541 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1393053 | (05) | LA |
E17516 | (02) | LA |