Provider Demographics
NPI:1629177472
Name:CAMPBELL, VIVIAN DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:DENISE
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:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-358-2700
Mailing Address - Fax:704-358-2716
Practice Address - Street 1:501 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1009
Practice Address - Country:US
Practice Address - Phone:704-358-2700
Practice Address - Fax:704-358-2716
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97002092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCN0020GMedicaid
NC5909693Medicaid
NC11104OtherBLUE CROSS BLUE SHIELD
NC2329442Medicare PIN
NCN0020GMedicaid
NC11104OtherBLUE CROSS BLUE SHIELD
G77803Medicare UPIN