Provider Demographics
NPI:1114345543
Name:CAMPBELL, BLAKE ALLEN (MD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ALLEN
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E 100 S
Mailing Address - Street 2:SUITE 200, UNIVERSITY OF UTAH HEALTH SCIENCE, GME
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-4211
Mailing Address - Country:US
Mailing Address - Phone:801-213-2735
Mailing Address - Fax:
Practice Address - Street 1:515 E 100 S
Practice Address - Street 2:SUITE 200, UNIVERSITY OF UTAH HEALTH SCIENCE, GME
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-4211
Practice Address - Country:US
Practice Address - Phone:801-213-2735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9529149-1205207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program