Provider Demographics
NPI:1861669988
Name:CAMPBELL, KIMBERLY JORDAN (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JORDAN
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 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:
Practice Address - Street 1:1203 IDAHO ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1940
Practice Address - Country:US
Practice Address - Phone:509-444-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM11531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
01-37459OtherMEDICA
MN1861669988OtherBCBS
1861669988OtherGROUP HEALTH
ID1861669988OtherREGENCE BLUE SHIELD
MN1861669988Medicaid
P00767193OtherMEDICARE RAILROAD
ID1861669988Medicaid
ID1861669988OtherREGENCE BLUE SHIELD
MN080018655Medicare PIN