Provider Demographics
NPI:1861074510
Name:CAMPBELL, GRANT MCKENZIE (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:MCKENZIE
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 1:86 W UNDERWOOD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1110
Mailing Address - Country:US
Mailing Address - Phone:321-841-5145
Mailing Address - Fax:
Practice Address - Street 1:10004 FOOTHILLS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-7102
Practice Address - Country:US
Practice Address - Phone:916-435-2700
Practice Address - Fax:916-435-2701
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
CAA193270207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program