Healthcare Provider Details

I. General information

NPI: 1871518662
Provider Name (Legal Business Name): DWIGHT CLESSON KELLICUT III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE RD
TRIPLER ARMY MEDICAL CENTER HI
96859-5001
US

IV. Provider business mailing address

4725 BOUGAINVILLE DR # 115
HONOLULU HI
96818-3179
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-6777
  • Fax:
Mailing address:
  • Phone: 864-455-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number01053701A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: