Provider Demographics
NPI:1407859770
Name:DEFONTES, CARLANN (DO)
Entity Type:Individual
Prefix:
First Name:CARLANN
Middle Name:
Last Name:DEFONTES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 408
Mailing Address - Street 2:VA CLINIC @ PAUL STEVENS OUTPATIENT CLINIC
Mailing Address - City:KAUNAKAKAI
Mailing Address - State:HI
Mailing Address - Zip Code:96748-0408
Mailing Address - Country:US
Mailing Address - Phone:360-929-9006
Mailing Address - Fax:
Practice Address - Street 1:280 HOME OLU PLACE VA CLINIC ,
Practice Address - Street 2:PAUL STEVENS OUTPATIENT CLINIC, MOLOKAI GENERAL HOSPITA
Practice Address - City:KAUNAKAKAI
Practice Address - State:HI
Practice Address - Zip Code:96748
Practice Address - Country:US
Practice Address - Phone:808-553-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS 1633207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COS94760Medicare UPIN
CO800206Medicare ID - Type Unspecified