Healthcare Provider Details

I. General information

NPI: 1053311548
Provider Name (Legal Business Name): CARY LEE CARPENTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 09/21/2025
Certification Date: 09/21/2025
Deactivation Date: 03/21/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

15679 NE 23RD ST
CHOCTAW OK
73020-8592
US

IV. Provider business mailing address

PO BOX 10
CHOCTAW OK
73020-0010
US

V. Phone/Fax

Practice location:
  • Phone: 405-390-9600
  • Fax:
Mailing address:
  • Phone: 405-390-9600
  • Fax: 405-390-9400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18237
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: