Provider Demographics
NPI:1295915304
Name:CARLOS CAMPOS MD PA CORP
Entity type:Organization
Organization Name:CARLOS CAMPOS MD PA CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:973-589-0767
Mailing Address - Street 1:44 FERRY ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-1466
Mailing Address - Country:US
Mailing Address - Phone:973-589-0767
Mailing Address - Fax:
Practice Address - Street 1:44 FERRY ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1466
Practice Address - Country:US
Practice Address - Phone:973-589-0767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ501416Medicare PIN