Provider Demographics
NPI:1073547543
Name:CARTER, KENNETH O (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:O
Last Name:CARTER
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 1:235 3RD AVE N UNIT 551
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3383
Mailing Address - Country:US
Mailing Address - Phone:704-953-8039
Mailing Address - Fax:
Practice Address - Street 1:1000 BAY PINES BLVD.
Practice Address - Street 2:
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744
Practice Address - Country:US
Practice Address - Phone:727-273-6828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1271032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT32836Medicaid
NC1073547543Medicaid
NC89133JFMedicaid
NCF62682Medicare UPIN
NC1073547543Medicaid
NC89133JFMedicaid