Provider Demographics
NPI:1164573192
Name:CARPENTER, DAVID WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WESLEY
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 1:77 W GRANADA BLVD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-6302
Mailing Address - Country:US
Mailing Address - Phone:386-677-0453
Mailing Address - Fax:386-677-5494
Practice Address - Street 1:77 W GRANADA BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-6302
Practice Address - Country:US
Practice Address - Phone:386-677-0453
Practice Address - Fax:386-677-5494
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86066207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH86718Medicare UPIN
FLU0860ZMedicare ID - Type UnspecifiedMCARE PERSONAL #
FL39678Medicare ID - Type UnspecifiedGROUP MEDICARE #