Provider Demographics
NPI:1518389022
Name:MODERN MALE T-CLINIC, P.A.
Entity Type:Organization
Organization Name:MODERN MALE T-CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SALVATORE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-246-5698
Mailing Address - Street 1:15340 DALLAS PKWY
Mailing Address - Street 2:STE2400
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-4636
Mailing Address - Country:US
Mailing Address - Phone:800-246-5698
Mailing Address - Fax:
Practice Address - Street 1:15340 DALLAS PKWY
Practice Address - Street 2:STE2400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-4636
Practice Address - Country:US
Practice Address - Phone:800-246-5698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty