Provider Demographics
NPI:1710066444
Name:CAMPOS, SARA E (MDPA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:E
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:MDPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 E BUSTAMANTE ST STE D
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-8905
Mailing Address - Country:US
Mailing Address - Phone:956-795-4750
Mailing Address - Fax:956-795-4753
Practice Address - Street 1:1501 E BUSTAMANTE ST STE D
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-8905
Practice Address - Country:US
Practice Address - Phone:956-795-4750
Practice Address - Fax:956-795-4753
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3290208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018021803Medicaid
TX0061HXOtherBC BC OF TEXAS
TX018021802Medicaid
TX0061HXOtherBC BC OF TEXAS