Provider Demographics
NPI:1922199546
Name:FENTON, CARTER PAGE JR (DO)
Entity Type:Individual
Prefix:
First Name:CARTER
Middle Name:PAGE
Last Name:FENTON
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15740 S OUTER 40 RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2004
Mailing Address - Country:US
Mailing Address - Phone:636-735-4205
Mailing Address - Fax:
Practice Address - Street 1:15740 S OUTER 40 RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2004
Practice Address - Country:US
Practice Address - Phone:636-735-4205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20111052207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
190050155OtherCPIN ST ANTHONYS
MO245164207Medicaid
930110488OtherRAILROAD
MO245164207Medicaid