Healthcare Provider Details

I. General information

NPI: 1528230133
Provider Name (Legal Business Name): ELIZABETH KRISTINE CAMPBELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 05/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 GLENDALE BLVD STE. 101
VALPARAISO IN
46383-3767
US

IV. Provider business mailing address

1101 GLENDALE BLVD STE. 101
VALPARAISO IN
46383-3767
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-0555
  • Fax:
Mailing address:
  • Phone: 219-462-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6348767-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01065148A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: