Provider Demographics
NPI:1487028791
Name:CAMPOS, MARTIN
Entity Type:Individual
Prefix:
First Name:MARTIN
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 1:1730 W OLYMPIC BLVD # 3A-300
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1019
Mailing Address - Country:US
Mailing Address - Phone:213-249-9388
Mailing Address - Fax:213-389-7993
Practice Address - Street 1:1730 W OLYMPIC BLVD # 3A-300
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-1019
Practice Address - Country:US
Practice Address - Phone:213-249-9388
Practice Address - Fax:213-389-7993
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator