Provider Demographics
NPI:1053311548
Name:CARPENTER, CARY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:CARY
Middle Name:LEE
Last Name:CARPENTER
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:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-0010
Mailing Address - Country:US
Mailing Address - Phone:405-390-9600
Mailing Address - Fax:405-390-9400
Practice Address - Street 1:15679 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8592
Practice Address - Country:US
Practice Address - Phone:405-390-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2022-09-28
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
OK18237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
900522085OtherMEDICARE GROUP PTAN - CARY CARPENTER M.D. PC DBA CHOCTAW FAMILY MEDICINE
OK100113820BMedicaid
OKF43282Medicare UPIN
OK100113820BMedicaid