Provider Demographics
NPI:1215182803
Name:GOSPHA G, CAMPBELL MD INC
Entity type:Organization
Organization Name:GOSPHA G, CAMPBELL MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GOSPHA
Authorized Official - Middle Name:G
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-890-9393
Mailing Address - Street 1:1850 S WATERMAN AVE, # F
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2464
Mailing Address - Country:US
Mailing Address - Phone:909-890-9393
Mailing Address - Fax:909-890-9394
Practice Address - Street 1:1850 S WATERMAN AVE # F
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2877
Practice Address - Country:US
Practice Address - Phone:909-890-9393
Practice Address - Fax:909-890-9394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 102029207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty