Provider Demographics
NPI:1073056107
Name:CAMPOS, REYNALDO
Entity Type:Individual
Prefix:
First Name:REYNALDO
Middle Name:
Last Name:CAMPOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7512 NW MORROCCO DR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-1222
Mailing Address - Country:US
Mailing Address - Phone:361-510-7129
Mailing Address - Fax:
Practice Address - Street 1:7512 NW MORROCCO DR
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-1222
Practice Address - Country:US
Practice Address - Phone:361-510-7129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor