Provider Demographics
NPI:1528172871
Name:CARPENTER, SAMUEL C (DPM)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:C
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:304 S LAKE ST
Mailing Address - Street 2:STE 104
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5659
Mailing Address - Country:US
Mailing Address - Phone:505-327-3338
Mailing Address - Fax:505-566-9213
Practice Address - Street 1:304 S LAKE ST
Practice Address - Street 2:STE 104
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5659
Practice Address - Country:US
Practice Address - Phone:505-327-3338
Practice Address - Fax:505-566-9213
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2014-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM171213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55640Medicaid
NM5695120001Medicare NSC
NM55640Medicaid
T41069Medicare UPIN
NM55640Medicaid