Healthcare Provider Details

I. General information

NPI: 1619955549
Provider Name (Legal Business Name): EDWIN L CLONTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KULOT DI ROSA DR. CHALAN KIYA HEALTH PROFESSIONAL CORPORATION
SAIPAN MP
96950-2878
US

IV. Provider business mailing address

PO BOX 502878
SAIPAN MP
96950-2878
US

V. Phone/Fax

Practice location:
  • Phone: 670-234-2901
  • Fax: 670-234-2906
Mailing address:
  • Phone: 670-234-2901
  • Fax: 670-234-2906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23309
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0522
License Number StateMP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: