Provider Demographics
NPI:1942224019
Name:CAMPBELL, DIANNE Q (MD)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:Q
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 1:1170 SHAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1618
Mailing Address - Country:US
Mailing Address - Phone:912-920-0214
Mailing Address - Fax:
Practice Address - Street 1:1170 SHAWNEE ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1618
Practice Address - Country:US
Practice Address - Phone:912-920-0214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00557334BMedicaid
GA08BBWKCOtherMEDICARE
GAF47133Medicare UPIN
GA08BBWKCMedicare ID - Type Unspecified