Provider Demographics
NPI:1053382481
Name:CAMPBELL, GARY G (OD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:G
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-1572
Mailing Address - Country:US
Mailing Address - Phone:781-871-1456
Mailing Address - Fax:
Practice Address - Street 1:17 NORTH AVE
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:MA
Practice Address - Zip Code:02370-2123
Practice Address - Country:US
Practice Address - Phone:781-878-1846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW15417OtherBLUE CROSS BLUE SHIELD
MA0337781Medicaid
MA0337781Medicaid
MA449958Medicare ID - Type Unspecified