Provider Demographics
NPI:1407053317
Name:COULTER, AMY HYOJUNG (M D)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:HYOJUNG
Last Name:COULTER
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 PORTLAND AVE
Mailing Address - Street 2:VASCULAR SURGERY
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3036
Mailing Address - Country:US
Mailing Address - Phone:585-922-5550
Mailing Address - Fax:
Practice Address - Street 1:1445 PORTLAND AVE
Practice Address - Street 2:VASCULAR SURGERY
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3036
Practice Address - Country:US
Practice Address - Phone:585-922-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.010858208600000X
LA205567208600000X
NY2773612086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04049092Medicaid
NYJ400193302-RGHMedicare PIN
NY04049092Medicaid