Provider Demographics
NPI:1285211029
Name:CAMPBELL, CHARLTON CARLYLE
Entity Type:Individual
Prefix:
First Name:CHARLTON
Middle Name:CARLYLE
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 1:330 MOSS ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-2005
Mailing Address - Country:US
Mailing Address - Phone:619-585-4221
Mailing Address - Fax:
Practice Address - Street 1:330 MOSS ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-2005
Practice Address - Country:US
Practice Address - Phone:619-585-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist