Healthcare Provider Details

I. General information

NPI: 1134238926
Provider Name (Legal Business Name): ANDREW C CAMPBELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10604 N PORT WASHINTON RD
MEQUON WI
53092-5013
US

IV. Provider business mailing address

10604 N. PORT WASHINGTON RD
MEQUON WI
53092
US

V. Phone/Fax

Practice location:
  • Phone: 262-242-7772
  • Fax: 262-478-0884
Mailing address:
  • Phone: 262-242-7772
  • Fax: 262-478-0884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number39563
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: