Provider Demographics
NPI:1073077988
Name:CLARENCE D HARKNESS DPM
Entity Type:Organization
Organization Name:CLARENCE D HARKNESS DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HARKNESS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:808-961-5700
Mailing Address - Street 1:73 PUUHONU PL STE 105
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2060
Mailing Address - Country:US
Mailing Address - Phone:808-961-5700
Mailing Address - Fax:808-961-5799
Practice Address - Street 1:73 PUUHONU PL STE 105
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2060
Practice Address - Country:US
Practice Address - Phone:808-961-5700
Practice Address - Fax:808-961-5799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI56938701Medicaid