Provider Demographics
NPI:1710979596
Name:CAMPBELL, ANGELA POTTER (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:POTTER
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANGELA
Other - Middle Name:PAIGE
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:901-227-4618
Mailing Address - Fax:901-447-5054
Practice Address - Street 1:6401 POPLAR AVE STE 610
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4806
Practice Address - Country:US
Practice Address - Phone:901-227-5045
Practice Address - Fax:901-224-5043
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36512207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3875694Medicaid
TN3875694Medicare ID - Type Unspecified
TNH67293Medicare UPIN
TN3875696Medicare ID - Type Unspecified