Provider Demographics
NPI:1386204626
Name:CAMPANA, MARIO SEBASTIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:SEBASTIAN
Last Name:CAMPANA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4422 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-2594
Mailing Address - Country:US
Mailing Address - Phone:718-960-6201
Mailing Address - Fax:
Practice Address - Street 1:103 THAYER ST APT C23
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-1036
Practice Address - Country:US
Practice Address - Phone:347-313-4294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program