Basic Information
| Provider Information | |||||||||
| NPI: | 1134415706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEFONTES | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8322 BELLONA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212042065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103377900 | ||||||||
| FaxNumber: | 4103375321 | ||||||||
| Practice Location | |||||||||
| Address1: | 8322 BELLONA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103377900 | ||||||||
| FaxNumber: | 4103375321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2011 | ||||||||
| LastUpdateDate: | 08/01/2018 | ||||||||
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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 | 207XX0004X | D0084939 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207X00000X | D0084939 | MD | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | D0084939 | 01 | MD | MARYLAND LICENSE | OTHER |