Provider Demographics
NPI:1427066554
Name:CARTER, KELLY ANNETTE (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANNETTE
Last Name:CARTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24850 SE STARK ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8316
Mailing Address - Country:US
Mailing Address - Phone:503-661-0464
Mailing Address - Fax:503-661-1420
Practice Address - Street 1:24850 SE STARK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8316
Practice Address - Country:US
Practice Address - Phone:503-661-0464
Practice Address - Fax:503-661-1420
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19343207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR074513Medicaid
ORG08089Medicare UPIN
OR074513Medicaid