Provider Demographics
NPI:1083627632
Name:CARTER, MARK ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
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 1:3907 JENICA WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1530
Mailing Address - Country:US
Mailing Address - Phone:502-412-2200
Mailing Address - Fax:502-429-3657
Practice Address - Street 1:3907 JENICA WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-1530
Practice Address - Country:US
Practice Address - Phone:502-412-2200
Practice Address - Fax:502-429-3657
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26799208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000001099444OtherANTHEM
KY152001OtherSIHO
KY7100054880Medicaid
KYP01349710OtherRAILROAD MEDICARE
KY000000844478OtherANTHEM
KYK087021OtherMEDICARE
KY152001OtherSIHO