Provider Demographics
NPI:1376527655
Name:YAMULLA, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:YAMULLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1347
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0347
Mailing Address - Country:US
Mailing Address - Phone:570-288-8881
Mailing Address - Fax:570-288-8065
Practice Address - Street 1:128 WEST 14TH ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-3266
Practice Address - Country:US
Practice Address - Phone:570-455-7677
Practice Address - Fax:570-455-7627
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2014-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031594E207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010850580001Medicaid
PA072376OtherFDH
PA0010850580001Medicaid
PA072376OtherFDH
PA122500Medicare ID - Type Unspecified