Healthcare Provider Details

I. General information

NPI: 1669524989
Provider Name (Legal Business Name): SUSAN CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 BALDWIN AVE
SAN MATEO CA
94401-3915
US

IV. Provider business mailing address

210 BALDWIN AVE
SAN MATEO CA
94401-3915
US

V. Phone/Fax

Practice location:
  • Phone: 650-579-7022
  • Fax: 650-579-7851
Mailing address:
  • Phone: 650-579-7022
  • Fax: 650-579-7851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG43015
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: