Provider Demographics
NPI:1225028921
Name:CAMPBELL, DOUGLAS G (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:G
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DOUGLAS
Other - Middle Name:G
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1717 SHAFFER ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1647
Mailing Address - Country:US
Mailing Address - Phone:269-226-5967
Mailing Address - Fax:
Practice Address - Street 1:1717 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1647
Practice Address - Country:US
Practice Address - Phone:269-226-5967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041491207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4541733Medicaid
MI4541733Medicaid
MIB46744Medicare UPIN
MI0P30590Medicare ID - Type Unspecified