Provider Demographics
NPI:1619918745
Name:CAMPBELL, MARK DORAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DORAN
Last Name:CAMPBELL
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 1:18444 N 25TH AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:623-537-5600
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:14520 W GRANITE VALLEY DR
Practice Address - Street 2:STE 210
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5855
Practice Address - Country:US
Practice Address - Phone:623-537-5600
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25777207XS0114X, 207XX0004X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5550830003OtherMEDICARE NSC PEORIA
AZ5550830001OtherMEDICARE NSC SCW
AZ5550830010OtherMEDICARE NSC GILBERT
AZP00207821OtherRR MEDICARE
AZ401448Medicaid
AZ5550830007OtherMEDICARE NSC DV
AZ5550830009OtherMEDICARE NSC AZ NORTH
AZ5550830009OtherMEDICARE NSC AZ NORTH
AZZ102177Medicare PIN