Provider Demographics
NPI:1417038100
Name:CARPENTER, MARY S (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 JACKSON STREET
Mailing Address - Street 2:PO BOX 358
Mailing Address - City:BURKE
Mailing Address - State:SD
Mailing Address - Zip Code:57523
Mailing Address - Country:US
Mailing Address - Phone:605-775-2631
Mailing Address - Fax:605-775-2564
Practice Address - Street 1:809 JACKSON ST
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:SD
Practice Address - Zip Code:57523-2065
Practice Address - Country:US
Practice Address - Phone:605-775-2631
Practice Address - Fax:605-775-2564
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0851370001OtherDME
SD5604133Medicaid
SD5604130Medicaid
SD5604132Medicaid
0851370001OtherDME
SD5604130Medicaid
NE$$$$$$$$$Medicaid
SD5604133Medicaid