Healthcare Provider Details

I. General information

NPI: 1720087919
Provider Name (Legal Business Name): KEVIN P CHARPENTIER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 CENTRE ST
BROCKTON MA
02302
US

IV. Provider business mailing address

680 CENTRE ST
BROCKTON MA
02302-3308
US

V. Phone/Fax

Practice location:
  • Phone: 508-941-7000
  • Fax: 508-941-0895
Mailing address:
  • Phone: 508-941-7885
  • Fax: 508-941-6337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number041519
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberMD12241
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number041519
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD12241
License Number StateRI
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number277097
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: