Provider Demographics
NPI:1831125806
Name:CARTER, MARK O (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:O
Last Name:CARTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9660 WICKER AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9487
Mailing Address - Country:US
Mailing Address - Phone:219-226-2203
Mailing Address - Fax:219-226-2202
Practice Address - Street 1:164 BRACKEN PKWY
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6789
Practice Address - Country:US
Practice Address - Phone:219-942-1145
Practice Address - Fax:219-942-8175
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036415A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000092031OtherANTHEM
IN100215600AMedicaid
IN00000092031OtherANTHEM
IN100215600AMedicaid