Provider Demographics
NPI:1558359174
Name:CARPENTER, MARTIN WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:WALLACE
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:MERCY MEDICAL CENTER
Mailing Address - Street 2:701 10TH STREET SE
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403
Mailing Address - Country:US
Mailing Address - Phone:319-369-4777
Mailing Address - Fax:319-369-4694
Practice Address - Street 1:MERCY MEDICAL CENTER
Practice Address - Street 2:701 10TH STREET SE
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403
Practice Address - Country:US
Practice Address - Phone:319-369-4777
Practice Address - Fax:319-369-4694
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA354222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA13725OtherBC PROVIDER NUMBER
IA36682Medicaid
I08023Medicare UPIN
IA36682Medicaid