=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700128394
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEKSANDR V. YULTYEV M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2013
-----------------------------------------------------
Last Update Date | 11/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 375 DIXMYTH AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45220-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-862-3229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5301 S CONGRESS AVE
-----------------------------------------------------
City | ATLANTIS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33462-1149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-832-2652
-----------------------------------------------------
Fax | 800-792-9021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | DR.0057177
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME133969
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------