Basic Information
| Provider Information | |||||||||
| NPI: | 1134165301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMELLO | ||||||||
| FirstName: | ELIOT | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 869 | ||||||||
| Address2: | |||||||||
| City: | WAIANAE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967920869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048051300 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Practice Location | |||||||||
| Address1: | 4643 WAIMEA CANYON RD | ||||||||
| Address2: | |||||||||
| City: | WAIMEA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048051300 | ||||||||
| FaxNumber: | 9048051302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 07/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD4005 | HI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207L00000X | MD-4005 | HI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 56214644596746A011 | 01 | HI | TRICARE | OTHER | 56214644596796A020 | 01 | HI | TRICARE | OTHER | 00298003 | 05 | HI | MEDICAID | 00298009 | 05 | HI | MEDICAID |