Provider Demographics
NPI:1073107298
Name:CAMPOS, LIZA MONICA
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:MONICA
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 N THOMPKINS AVE APT S3
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-5334
Mailing Address - Country:US
Mailing Address - Phone:405-658-3455
Mailing Address - Fax:
Practice Address - Street 1:7117 E RENO AVE
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4444
Practice Address - Country:US
Practice Address - Phone:405-610-5242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty