Healthcare Provider Details

I. General information

NPI: 1033603766
Provider Name (Legal Business Name): EDWIN CAMPOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2018
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 PARK AVE
NEW YORK NY
10029-3810
US

IV. Provider business mailing address

639 BOND CT
NORTH MERRICK NY
11566-1240
US

V. Phone/Fax

Practice location:
  • Phone: 212-426-3400
  • Fax:
Mailing address:
  • Phone: 646-619-7744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number099513
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: