Provider Demographics
NPI:1316942097
Name:CAMPBELL, CATHLEEN (MD)
Entity type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:99 ASH ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3226
Practice Address - Country:US
Practice Address - Phone:860-282-8510
Practice Address - Fax:860-282-8586
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT035856207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1316942097Medicaid
CT160002021Medicare PIN
CTG47500Medicare UPIN