Provider Demographics
NPI:1720087919
Name:CHARPENTIER, KEVIN P (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:CHARPENTIER
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 1:680 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:508-941-7885
Mailing Address - Fax:508-941-6337
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302
Practice Address - Country:US
Practice Address - Phone:508-941-7000
Practice Address - Fax:508-941-0895
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041519204F00000X, 208600000X
RIMD12241204F00000X, 208600000X
MA277097208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7059024Medicaid
RI007059007Medicare PIN
RI7059024Medicaid