Provider Demographics
NPI:1750373239
Name:CAMPBELL, DAVID L (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 GLASSON WAY STE L10
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5723
Practice Address - Country:US
Practice Address - Phone:530-274-6677
Practice Address - Fax:530-274-6678
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2019-10-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG64781207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
68-0334230OtherPREVIOUS TAX ID NUMBER PRIOR TO 11/2006
DF1247OtherRAILROAD MEDICARE CURRENT PTAN 08/2010
ZZZ02732ZOtherCURRENT MEDICARE PTAN 11/2006
20-5308894OtherCURRENT TAX ID NUMBER 11/2006
CAP00340104OtherRAILROAD MEDICARE PTAN
CAGR0061600OtherST OF CA MEDI-CAL #
CAGR0061600OtherST OF CA MEDI-CAL #
CAE95790Medicare UPIN
DF1247OtherRAILROAD MEDICARE CURRENT PTAN 08/2010