Provider Demographics
NPI:1821043803
Name:DANFORTH, WENDELL CALVIN (M D)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:CALVIN
Last Name:DANFORTH
Suffix:
Gender:M
Credentials:M D
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 1300
Mailing Address - Street 2:MAILCODE 61322
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96807-1300
Mailing Address - Country:US
Mailing Address - Phone:808-955-0255
Mailing Address - Fax:808-955-4155
Practice Address - Street 1:1001 KAMOKILA BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2014
Practice Address - Country:US
Practice Address - Phone:808-674-2727
Practice Address - Fax:808-674-2500
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD12871207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIG94414Medicare UPIN
MNG94414Medicare UPIN
MN61322300Medicaid