Healthcare Provider Details

I. General information

NPI: 1770571432
Provider Name (Legal Business Name): MARK STEVEN CAMPBELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 5TH ST STE 2
DOUGLAS WY
82633-2434
US

IV. Provider business mailing address

PO BOX 1450
DOUGLAS WY
82633-1450
US

V. Phone/Fax

Practice location:
  • Phone: 307-358-7365
  • Fax: 307-358-7347
Mailing address:
  • Phone: 307-358-2122
  • Fax: 307-358-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number39321
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: