Basic Information
Provider Information | |||||||||
NPI: | 1912983735 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CAMPBELL | ||||||||
FirstName: | VIDA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ASHRAF | ||||||||
OtherFirstName: | VIDA | ||||||||
OtherMiddleName: | S. | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2350 W EL CAMINO REAL FL 2 | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN VIEW | ||||||||
State: | CA | ||||||||
PostalCode: | 940406203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4158843418 | ||||||||
FaxNumber: | 4158838082 | ||||||||
Practice Location | |||||||||
Address1: | 795 EL CAMINO REAL | ||||||||
Address2: |   | ||||||||
City: | PALO ALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 943012302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6508532955 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2005 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | G79049 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | MD00032481 | WA | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | MD0003241 | WA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | G79049 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 8279051 | 05 | WA |   | MEDICAID | 300123267 | 01 | WA | RAILROAD MEDICARE | OTHER | 00G790490 | 05 | CA |   | MEDICAID | 300121747 | 01 | CA | RAILROAD MEDICARE | OTHER |