Healthcare Provider Details

I. General information

NPI: 1871020230
Provider Name (Legal Business Name): HELENA INTAN KURNIAWAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 W BALTIMORE PIKE
MEDIA PA
19063-5104
US

IV. Provider business mailing address

3803 W CHESTER PIKE STE 160
NEWTOWN SQUARE PA
19073-2336
US

V. Phone/Fax

Practice location:
  • Phone: 484-227-4280
  • Fax:
Mailing address:
  • Phone: 484-337-1632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOT017922
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberETLL-502
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS024938
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberETLL-502
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number285135
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberOS024938
License Number StatePA
# 7
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MB11944400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: