Provider Demographics
NPI:1083628770
Name:CAMPBELL, MICAL S (MD)
Entity Type:Individual
Prefix:
First Name:MICAL
Middle Name:S
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:COASTAL DIGESTIVE DISEASES
Mailing Address - Street 2:234A BANK ST
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320
Mailing Address - Country:US
Mailing Address - Phone:860-442-0290
Mailing Address - Fax:860-442-2136
Practice Address - Street 1:COASTAL DIGESTIVE DISEASES
Practice Address - Street 2:234A BANK ST
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-442-0290
Practice Address - Fax:860-442-2136
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-12-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT044903207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA10128700Medicaid
PA10128700Medicaid
PAI27344Medicare UPIN