Provider Demographics
NPI:1780816447
Name:CAMPBELL, AUDREY L (DO)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:215 E SPRINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1761
Mailing Address - Country:US
Mailing Address - Phone:423-794-5520
Mailing Address - Fax:423-282-6940
Practice Address - Street 1:301 MED TECH PKWY STE 240
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2641
Practice Address - Country:US
Practice Address - Phone:423-794-5520
Practice Address - Fax:423-282-6940
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116021790207R00000X
TN2439207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1780816447Medicaid
VA1780816447Medicaid
TNQ000732Medicaid
KY7100238500Medicaid
TNP01302087OtherRR MEDICARE
TN103I116063Medicare PIN