Provider Demographics
NPI:1487820429
Name:KUNTJORO, IVANDITO (MD)
Entity Type:Individual
Prefix:
First Name:IVANDITO
Middle Name:
Last Name:KUNTJORO
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 1:9000 ALMEDA RD
Mailing Address - Street 2:1102
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-4300
Mailing Address - Country:US
Mailing Address - Phone:713-492-7218
Mailing Address - Fax:
Practice Address - Street 1:9000 ALMEDA ROAD
Practice Address - Street 2:1102
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054
Practice Address - Country:US
Practice Address - Phone:713-492-7218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57012187207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine