Provider Demographics
NPI:1417901232
Name:CAMPBELL, JOHN N (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:N
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 1:1676 VIEWPOND DR SE STE 100A
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-4994
Mailing Address - Country:US
Mailing Address - Phone:616-455-9450
Mailing Address - Fax:616-455-5221
Practice Address - Street 1:1676 VIEWPOND DR SE
Practice Address - Street 2:SUITE 100A
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-4994
Practice Address - Country:US
Practice Address - Phone:616-455-9450
Practice Address - Fax:616-455-5221
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI034105207R00000X
MI4301034105207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1598853608OtherGROUP NPI
MI1076881Medicaid
MI382161547OtherTAX ID
MIB45563Medicare UPIN
MI0P28470Medicare PIN