Provider Demographics
NPI:1407344989
Name:CAMPBELL, THANE ROBERT (MD)
Entity type:Individual
Prefix:
First Name:THANE
Middle Name:ROBERT
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6301 STADIUM DR # 500
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8766
Practice Address - Country:US
Practice Address - Phone:336-766-6473
Practice Address - Fax:336-766-8909
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC238751390200000X
NC2021-00771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty