Provider Demographics
NPI:1073508404
Name:CARPENTER, CHARLES JACKIE JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JACKIE
Last Name:CARPENTER
Suffix:JR
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 6599
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-6599
Mailing Address - Country:US
Mailing Address - Phone:334-699-7900
Mailing Address - Fax:334-699-7901
Practice Address - Street 1:4300 W MAIN ST STE 21
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1058
Practice Address - Country:US
Practice Address - Phone:334-793-9564
Practice Address - Fax:334-671-8907
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17706208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000032574Medicaid
1073508404OtherNPI
GA00801743AMedicaid
1073508404OtherNPI
AL000032574Medicare ID - Type Unspecified
ALI572Medicare UPIN
GA00801743AMedicaid