Healthcare Provider Details

I. General information

NPI: 1578509980
Provider Name (Legal Business Name): KEVIN R CARPENTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 NW DIVISION ST
GRESHAM OR
97030-5506
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-9500
  • Fax: 503-215-9525
Mailing address:
  • Phone: 503-215-6494
  • Fax: 503-215-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD20344
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier080102978
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerRR MEDICARE (PH&S)-PMG
# 2
Identifier150062
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: