Provider Demographics
NPI:1629055439
Name:CARPENTER, RANDALL K (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:K
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 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:333 N OAK ST
Practice Address - Street 2:SUITE F
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1600
Practice Address - Country:US
Practice Address - Phone:260-248-9090
Practice Address - Fax:260-248-9095
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01020756A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00262546OtherRAILROAD MEDICARE
IN100262990Medicaid
IN1152OtherPHYSICIANS HEALTH PLAN
IN000000376732OtherANTHEM
IN100262990Medicaid
IN070860UMedicare PIN