Healthcare Provider Details

I. General information

NPI: 1588650600
Provider Name (Legal Business Name): WILLIAM MACRAE CAMPBELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 MINNEQUA AVE
PUEBLO CO
81004-3734
US

IV. Provider business mailing address

1120 MINNEQUA AVE
PUEBLO CO
81004-3734
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-0660
  • Fax: 719-564-0037
Mailing address:
  • Phone: 719-564-0660
  • Fax: 719-564-0037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number16123
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: