Healthcare Provider Details

I. General information

NPI: 1104880160
Provider Name (Legal Business Name): RUSSELL WITTER CAMPBELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 STRAWBERRY PLAINS RD SUITE A
WILLIAMSBURG VA
23188-3409
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD SUITE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 757-229-7939
  • Fax: 757-229-7897
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number51819
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number0101046591
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: