Provider Demographics
NPI:1558384917
Name:CAMPBELL, COLLEEN C (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:C
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 TAVISTOCK LAKES BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7592
Mailing Address - Country:US
Mailing Address - Phone:321-332-6947
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:9740 N 56TH ST STE B
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-5500
Practice Address - Country:US
Practice Address - Phone:813-200-7717
Practice Address - Fax:813-985-8500
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88894207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL281186300Medicaid
FL82103ZMedicare PIN
FL281186300Medicaid