Basic Information
| Provider Information | |||||||||
| NPI: | 1942298112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E 2ND ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757897000 | ||||||||
| FaxNumber: | 7757897040 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E 2ND ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757897000 | ||||||||
| FaxNumber: | 7757897040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 11/04/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 4665 | NV | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | CC4367 | 01 | NV | ANTHEM BCBS | OTHER | XPY187231 | 05 | CA | MEDICAID | 002016467 | 05 | NV | MEDICAID | CC4367 | 01 | BCBS | OTHER |