Provider Demographics
NPI:1184653065
Name:CAMPBELL, DANIEL BRUCE
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:BRUCE
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 LOBERG AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2652
Mailing Address - Country:US
Mailing Address - Phone:218-249-5700
Mailing Address - Fax:218-249-4666
Practice Address - Street 1:4190 LOBERG AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-2652
Practice Address - Country:US
Practice Address - Phone:218-249-5700
Practice Address - Fax:218-249-4666
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27762207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30355800Medicaid
WI30355800Medicaid
WI30355800Medicaid