Provider Demographics
NPI:1629028956
Name:CARPENTER, KEVIN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
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:PO BOX 3178
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52406-3178
Mailing Address - Country:US
Mailing Address - Phone:319-398-1583
Mailing Address - Fax:319-399-2085
Practice Address - Street 1:202 10TH STREET SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2404
Practice Address - Country:US
Practice Address - Phone:319-399-2022
Practice Address - Fax:319-399-2014
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28759207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA22504OtherBLUE CROSS/BLUE SHIELD
IA0219329Medicaid
IA10485Medicare ID - Type Unspecified
IA0219329Medicaid