Healthcare Provider Details

I. General information

NPI: 1972726446
Provider Name (Legal Business Name): CARTER P FENTON SR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 S MAIN ST
CHAFFEE MO
63740-1002
US

IV. Provider business mailing address

206 S MAIN ST
CHAFFEE MO
63740-1002
US

V. Phone/Fax

Practice location:
  • Phone: 573-887-3688
  • Fax: 573-887-9022
Mailing address:
  • Phone: 573-887-3688
  • Fax: 573-887-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31606
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: