Provider Demographics
NPI:1306012935
Name:CAMPBELL, GOSPHA GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:GOSPHA
Middle Name:GORDON
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 1:1850 S WATERMAN AVE # F
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2877
Mailing Address - Country:US
Mailing Address - Phone:909-890-9393
Mailing Address - Fax:909-890-9394
Practice Address - Street 1:1850 S WATERMAN AVE, # F
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:909-890-9393
Practice Address - Fax:909-890-9394
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-04
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102029207Q00000X
PR16775207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine