Basic Information
| Provider Information | |||||||||
| NPI: | 1770571432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1450 | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826331450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582122 | ||||||||
| FaxNumber: | 3073587347 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S 5TH ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826332434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073587365 | ||||||||
| FaxNumber: | 3073587347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 11/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 39321 | CO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 50424203 | 05 | CO | MEDICAID |