Provider Demographics
NPI:1851444228
Name:GULTOM, YANTO MEIYER (MD)
Entity Type:Individual
Prefix:DR
First Name:YANTO
Middle Name:MEIYER
Last Name:GULTOM
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 1:75 WILLOCKS CIR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-7462
Mailing Address - Country:US
Mailing Address - Phone:732-322-5223
Mailing Address - Fax:908-382-3288
Practice Address - Street 1:403 TOWNE CENTRE DR
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NJ
Practice Address - Zip Code:08844-4698
Practice Address - Country:US
Practice Address - Phone:908-428-4840
Practice Address - Fax:908-382-3288
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07450700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ073292V9DMedicare ID - Type Unspecified