Provider Demographics
NPI:1215948633
Name:CAMPBELL, MARK RICHARD (MSPT, OCS, CMPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MSPT, OCS, CMPT
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 3178
Mailing Address - Street 2:
Mailing Address - City:TELLURIDE
Mailing Address - State:CO
Mailing Address - Zip Code:81435-3178
Mailing Address - Country:US
Mailing Address - Phone:970-728-1888
Mailing Address - Fax:
Practice Address - Street 1:300 W. COLORADO AVE
Practice Address - Street 2:UNIT 2B
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435-3178
Practice Address - Country:US
Practice Address - Phone:970-728-1888
Practice Address - Fax:970-369-4671
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5562208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
COD2323Medicare ID - Type Unspecified