Provider Demographics
NPI:1417148081
Name:YONGKUMA, YONGKUMA C (MD)
Entity Type:Individual
Prefix:
First Name:YONGKUMA
Middle Name:C
Last Name:YONGKUMA
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 1:1212 E THREE NOTCH ST
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-3402
Mailing Address - Country:US
Mailing Address - Phone:334-222-6041
Mailing Address - Fax:334-222-1595
Practice Address - Street 1:1212 E THREE NOTCH ST
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-3402
Practice Address - Country:US
Practice Address - Phone:334-222-6041
Practice Address - Fax:334-222-1595
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL29462207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000109308Medicaid
102I113291Medicare PIN