Provider Demographics
NPI:1619069622
Name:CAMPBELL, CHARLES WALTON (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WALTON
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 1:102 CARROLLTON ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39095
Mailing Address - Country:US
Mailing Address - Phone:662-834-1721
Mailing Address - Fax:662-834-1721
Practice Address - Street 1:102 CARROLLTON ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095
Practice Address - Country:US
Practice Address - Phone:662-834-1721
Practice Address - Fax:662-834-1721
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
258908OtherRHC PROVIDER
MS0011518Medicaid
C48268Medicare UPIN