Provider Demographics
NPI:1801855499
Name:CAMPBELL, ELLEN F (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:F
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 1:11710 NEWBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-3500
Mailing Address - Country:US
Mailing Address - Phone:703-981-2289
Mailing Address - Fax:
Practice Address - Street 1:11710 NEWBRIDGE CT
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3500
Practice Address - Country:US
Practice Address - Phone:703-981-2289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052547207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG38064Medicare UPIN
VAG00481Medicare PIN
VAG00481Medicare ID - Type Unspecified