Healthcare Provider Details

I. General information

NPI: 1134415706
Provider Name (Legal Business Name): KENNETH WILLIAM DEFONTES III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8322 BELLONA AVE STE 100
TOWSON MD
21204
US

IV. Provider business mailing address

8322 BELLONA AVE STE 100
TOWSON MD
21204-2065
US

V. Phone/Fax

Practice location:
  • Phone: 410-337-7900
  • Fax: 410-337-5321
Mailing address:
  • Phone: 410-337-7900
  • Fax: 410-337-5321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberD0084939
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberD0084939
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: