Provider Demographics
NPI:1134415706
Name:DEFONTES, KENNETH WILLIAM III (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:DEFONTES
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8322 BELLONA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2065
Mailing Address - Country:US
Mailing Address - Phone:410-337-7900
Mailing Address - Fax:410-337-5321
Practice Address - Street 1:8322 BELLONA AVE STE 100
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204
Practice Address - Country:US
Practice Address - Phone:410-337-7900
Practice Address - Fax:410-337-5321
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0084939207XX0004X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0084939OtherMARYLAND LICENSE