Provider Demographics
NPI:1073541090
Name:CAMPBELL, MARK ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
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 1:420 N COLLEGIATE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460
Mailing Address - Country:US
Mailing Address - Phone:903-785-4499
Mailing Address - Fax:903-785-4717
Practice Address - Street 1:420 N COLLEGIATE DR
Practice Address - Street 2:STE 300
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460
Practice Address - Country:US
Practice Address - Phone:903-785-4499
Practice Address - Fax:903-785-4717
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3809208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128162804Medicaid
C14130Medicare UPIN
TX128162804Medicaid