Provider Demographics
NPI:1669524989
Name:CAMPBELL, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3915
Mailing Address - Country:US
Mailing Address - Phone:650-579-7022
Mailing Address - Fax:650-579-7851
Practice Address - Street 1:210 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3915
Practice Address - Country:US
Practice Address - Phone:650-579-7022
Practice Address - Fax:650-579-7851
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43015208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics