Provider Demographics
NPI:1760545479
Name:CAMPBELL, SUSAN KELLER (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KELLER
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 1:8650 SUDLEY RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4419
Mailing Address - Country:US
Mailing Address - Phone:703-393-9494
Mailing Address - Fax:703-393-8591
Practice Address - Street 1:8650 SUDLEY RD
Practice Address - Street 2:SUITE 306
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4419
Practice Address - Country:US
Practice Address - Phone:703-393-9494
Practice Address - Fax:703-393-8591
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154106OtherUNITED HEALTHCARE MAMSI
VA005635675Medicaid
334844OtherANTHEM HEALTHKEEPERS PLUS
804791OtherAETNA
50320001OtherCAREFIRST
259951OtherUNITED HEALTHCARE MAMSI
8154106OtherUNITED HEALTHCARE MAMSI