Provider Demographics
NPI:1164284139
Name:MOCK, CAMPBELL GRAY
Entity Type:Individual
Prefix:
First Name:CAMPBELL
Middle Name:GRAY
Last Name:MOCK
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 1:785 JASMINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36093-1753
Mailing Address - Country:US
Mailing Address - Phone:334-312-5982
Mailing Address - Fax:
Practice Address - Street 1:7076 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-4242
Practice Address - Country:US
Practice Address - Phone:334-290-4501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program