Basic Information
| Provider Information | |||||||||
| NPI: | 1790765089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 LAKEVIEW RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274424178 | ||||||||
| FaxNumber: | 7274422390 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 LAKEVIEW RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138908004 | ||||||||
| FaxNumber: | 8132909691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 03/02/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 036817200 | 05 | FL | MEDICAID |