Provider Demographics
NPI:1720117195
Name:CHARPENTIER, MARK LEON (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEON
Last Name:CHARPENTIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 ANDREW DR
Mailing Address - Street 2:
Mailing Address - City:FLOYDS KNOBS
Mailing Address - State:IN
Mailing Address - Zip Code:47119-9364
Mailing Address - Country:US
Mailing Address - Phone:502-558-5990
Mailing Address - Fax:
Practice Address - Street 1:1373 E STATE ROAD 62
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-7328
Practice Address - Country:US
Practice Address - Phone:812-801-0152
Practice Address - Fax:812-801-0150
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058005A2080P0203X, 208000000X, 2080P0204X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200472340Medicaid
KY7100294420Medicaid