Healthcare Provider Details

I. General information

NPI: 1407053317
Provider Name (Legal Business Name): AMY HYOJUNG COULTER M. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 PORTLAND AVE VASCULAR SURGERY
ROCHESTER NY
14621-3036
US

IV. Provider business mailing address

1445 PORTLAND AVE VASCULAR SURGERY
ROCHESTER NY
14621-3036
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-5550
  • Fax:
Mailing address:
  • Phone: 585-922-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number57.010858
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number205567
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number277361
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: