Provider Demographics
NPI:1265627145
Name:KUSUMA, YULIANTY D (MD)
Entity type:Individual
Prefix:
First Name:YULIANTY
Middle Name:D
Last Name:KUSUMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:YULIANTY
Other - Middle Name:D
Other - Last Name:HEANACHO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6413 WATERS AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2711
Mailing Address - Country:US
Mailing Address - Phone:912-349-6624
Mailing Address - Fax:912-354-4694
Practice Address - Street 1:6413 WATERS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2711
Practice Address - Country:US
Practice Address - Phone:912-349-6624
Practice Address - Fax:912-354-4694
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061279207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA007011626AMedicaid
GA52233988OtherBCBS
01279332OtherAMERIGROUP
GA469648OtherWELLCARE
GAP01048571OtherRAILROAD MEDICARE
GAP00649653OtherRR MEDICARE
SCG61279Medicaid
GAP00649653OtherRR MEDICARE
SCG61279Medicaid