Provider Demographics
NPI:1659547248
Name:B.L. CARPENTER, M.D. CLINIC, PLLC
Entity Type:Organization
Organization Name:B.L. CARPENTER, M.D. CLINIC, PLLC
Other - Org Name:B.L. CARPENTER, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/SOLE PROPRIATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-623-7444
Mailing Address - Street 1:203 N WEIGLE AVE
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-3840
Mailing Address - Country:US
Mailing Address - Phone:580-623-7444
Mailing Address - Fax:580-623-7447
Practice Address - Street 1:203 N WEIGLE AVE
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-3840
Practice Address - Country:US
Practice Address - Phone:580-623-7444
Practice Address - Fax:580-623-7447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100230090AMedicaid
OK100230090AMedicaid
OK200522057Medicare PIN