Provider Demographics
NPI:1134165301
Name:DEMELLO, ELIOT A (MD)
Entity type:Individual
Prefix:
First Name:ELIOT
Middle Name:A
Last Name:DEMELLO
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:PO BOX 869
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-0869
Mailing Address - Country:US
Mailing Address - Phone:904-805-1300
Mailing Address - Fax:904-805-1302
Practice Address - Street 1:4643 WAIMEA CANYON RD
Practice Address - Street 2:
Practice Address - City:WAIMEA
Practice Address - State:HI
Practice Address - Zip Code:96796
Practice Address - Country:US
Practice Address - Phone:904-805-1300
Practice Address - Fax:904-805-1302
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD4005207P00000X
HIMD-4005207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI56214644596746A011OtherTRICARE
HI56214644596796A020OtherTRICARE
HI00298003Medicaid
HI00298009Medicaid
HID43414Medicare UPIN
HI100336Medicare ID - Type Unspecified