Provider Demographics
NPI:1982685236
Name:CARPENTER, MARK MERRITT (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MERRITT
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 1:420 LOWELL DR SE
Mailing Address - Street 2:STE 103
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3754
Mailing Address - Country:US
Mailing Address - Phone:256-535-5940
Mailing Address - Fax:256-535-5954
Practice Address - Street 1:101 BOB WALLACE AVE SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3843
Practice Address - Country:US
Practice Address - Phone:256-533-0335
Practice Address - Fax:256-539-9880
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9843208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51051905OtherBLUE CROSS BLUE SHIELD
0004003511OtherAETNA IDENTIFICATION NO
AL000051905Medicaid
020045088Medicare ID - Type UnspecifiedRAILROAD MEDICARE NO
0004003511OtherAETNA IDENTIFICATION NO
000051905Medicare ID - Type Unspecified