Provider Demographics
NPI:1093100646
Name:CAMPBELL, DOUGLAS D (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:D
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:887 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3100
Mailing Address - Country:US
Mailing Address - Phone:207-774-6368
Mailing Address - Fax:
Practice Address - Street 1:887 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3100
Practice Address - Country:US
Practice Address - Phone:207-774-6368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0060093207LC0200X, 207P00000X
MEMD23589207LC0200X, 207PE0004X
MA264348207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1093100646Medicaid