Healthcare Provider Details

I. General information

NPI: 1164943635
Provider Name (Legal Business Name): YULIUS LEONARD HARYADI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MEMBERS WAY FL 5
DOVER NH
03820-5933
US

IV. Provider business mailing address

789 CENTRAL AVE
DOVER NH
03820-2526
US

V. Phone/Fax

Practice location:
  • Phone: 603-609-6800
  • Fax: 603-609-6820
Mailing address:
  • Phone: 603-609-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20209
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number20209
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: