Provider Demographics
NPI:1124355144
Name:CAMPBELL, CONSTANCE BLAIR (MD)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:BLAIR
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 PACIFIC AVE
Mailing Address - Street 2:STE. 300
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4443
Mailing Address - Country:US
Mailing Address - Phone:253-722-1540
Mailing Address - Fax:253-597-4556
Practice Address - Street 1:10510 GRAVELLY LAKE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-5036
Practice Address - Country:US
Practice Address - Phone:253-589-7030
Practice Address - Fax:253-589-7033
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60463468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD9572Medicaid