Healthcare Provider Details

I. General information

NPI: 1396033072
Provider Name (Legal Business Name): DUSTIN CHARLES CARPENTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 STATE ST
MOUND CITY MO
64470-1145
US

IV. Provider business mailing address

909 N 6TH ST
TARKIO MO
64491-1119
US

V. Phone/Fax

Practice location:
  • Phone: 660-686-2329
  • Fax: 660-686-2799
Mailing address:
  • Phone: 816-309-8028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6444
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: