Provider Demographics
NPI:1639216575
Name:CARPENTER, RICHARD OWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:OWEN
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 1:987 CANTON ST BLDG 14
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4240
Mailing Address - Country:US
Mailing Address - Phone:404-939-4771
Mailing Address - Fax:404-420-2697
Practice Address - Street 1:987 CANTON ST BLDG 14
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-4240
Practice Address - Country:US
Practice Address - Phone:404-420-2697
Practice Address - Fax:404-420-2697
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0371652084P0005X, 2084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000557884BMedicaid
GA000557884BMedicaid