Provider Demographics
NPI:1285647826
Name:DUNDAS, CHARLES GLENN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:GLENN
Last Name:DUNDAS
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 1:346 WAIANUENUE AVE
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2447
Mailing Address - Country:US
Mailing Address - Phone:808-319-2939
Mailing Address - Fax:808-935-5095
Practice Address - Street 1:346 WAIANUENUE AVE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2447
Practice Address - Country:US
Practice Address - Phone:808-319-2939
Practice Address - Fax:808-935-5095
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5763207Q00000X
HI16511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139971913Medicaid
TXE07447Medicare UPIN
TX139971913Medicaid
TXE07447Medicare UPIN