Provider Demographics
NPI:1417911033
Name:CAMPBELL, ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
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:PO BOX 34935
Mailing Address - Street 2:DEPARTMENT 563
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1935
Mailing Address - Country:US
Mailing Address - Phone:888-633-0079
Mailing Address - Fax:
Practice Address - Street 1:280 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1552
Practice Address - Country:US
Practice Address - Phone:503-482-2441
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
97520A004OtherCHAMPUS
F32127OtherPROVIDENCE HEALTH PLANS
XPY186019OtherMEDI-CAL
F32127OtherGROUP HEALTH
OR0064852Medicaid
XPY186019OtherMEDI-CAL
F32127OtherGROUP HEALTH