MEDICARE: DR. EDWIN L CLONTS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	23309	MN
2	207Q00000X	Family Medicine Physician	0522	MP

General Provider Information

NPI Number	:	1619955549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWIN L CLONTS MD

Provider Business Mailing Address
First Line	:	PO BOX 502878
Second Line	:
City	:	SAIPAN
State	:	MP
Zip	:	96950-2878
Country	:	US
Telephone Number	:	670-234-2901
Fax Number	:	670-234-2906

Provider Business Practice Location Address
First Line	:	KULOT DI ROSA DR. CHALAN KIYA
Second Line	:	HEALTH PROFESSIONAL CORPORATION
City	:	SAIPAN
State	:	MP
Zip	:	96950-2878
Country	:	US
Telephone Number	:	670-234-2901
Fax Number	:	670-234-2906

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	09/12/2012

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