Basic Information
| Provider Information | |||||||||
| NPI: | 1073508404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JACKIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6599 | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363026599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346997900 | ||||||||
| FaxNumber: | 3346997901 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 W MAIN ST STE 21 | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363051058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347939564 | ||||||||
| FaxNumber: | 3346718907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 17706 | AL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000032574 | 05 | AL | MEDICAID | 1073508404 | 01 | NPI | OTHER | 00801743A | 05 | GA | MEDICAID |