Provider Demographics
NPI:1861669988
Name:CAMPBELL, KIMBERLY JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JORDAN
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 1:607 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1345
Mailing Address - Country:US
Mailing Address - Phone:208-983-1700
Mailing Address - Fax:208-983-4665
Practice Address - Street 1:607 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1345
Practice Address - Country:US
Practice Address - Phone:208-983-1700
Practice Address - Fax:208-983-4665
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM11531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1861669988OtherGROUP HEALTH
P00767193OtherMEDICARE RAILROAD
MN1861669988OtherBCBS
MN1861669988Medicaid
01-37459OtherMEDICA
ID1861669988Medicaid
ID1861669988OtherREGENCE BLUE SHIELD
ID1861669988OtherREGENCE BLUE SHIELD
MN080018655Medicare PIN