Provider Demographics
NPI:1417956210
Name:CARPENTER, MARTIN WAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:WAYNE
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 MORGANTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-4331
Mailing Address - Country:US
Mailing Address - Phone:304-366-4721
Mailing Address - Fax:304-366-4847
Practice Address - Street 1:709 MORGANTOWN AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-4331
Practice Address - Country:US
Practice Address - Phone:304-366-4721
Practice Address - Fax:304-366-4847
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1013-00152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3101032000Medicaid
CA4113131Medicare ID - Type Unspecified
U96198Medicare UPIN