Provider Demographics
NPI:1740281997
Name:CAMPBELL, DONALD A JR
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:A
Last Name:CAMPBELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11270 E 13 MILE RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2599
Mailing Address - Country:US
Mailing Address - Phone:586-574-0630
Mailing Address - Fax:586-574-0636
Practice Address - Street 1:11270 E 13 MILE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2599
Practice Address - Country:US
Practice Address - Phone:586-574-0630
Practice Address - Fax:586-574-0636
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046758207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E031610OtherBCBSM GROUP NUMBER
MN0500014OtherBCBSM PIN
A73511Medicare UPIN
MIMI3971052Medicare PIN