Provider Demographics
NPI:1497757520
Name:CARPENTER, JULIE J (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:J
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:JACKSON-CARPENTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1022 N GERMANTOWN PKWY
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-5892
Mailing Address - Country:US
Mailing Address - Phone:901-254-8500
Mailing Address - Fax:901-754-8578
Practice Address - Street 1:3451 GOODMAN RD E STE 115
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9304
Practice Address - Country:US
Practice Address - Phone:662-890-5555
Practice Address - Fax:662-890-8899
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00181717OtherMEDICARE RAILROAD
MSH37663Medicare UPIN
MS080004002Medicare PIN