Provider Demographics
NPI:1992916241
Name:HERMANTO, ULRICH (MD, PHD)
Entity type:Individual
Prefix:
First Name:ULRICH
Middle Name:
Last Name:HERMANTO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPARTMENT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:970 N BROADWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1309
Practice Address - Country:US
Practice Address - Phone:914-969-1600
Practice Address - Fax:914-969-1685
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2443122085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY244312-A2BOtherHEALTH FIRST
NYUHERMANTOOtherNEIGHBORHOOD HEALTH PROVIDERS
NYP3847380OtherOXFORD PROVIDER ID #
NY01317811OtherAMERIGROUP
NY02902358Medicaid
NY1000060372OtherAFFINITY PROVIDER #
NY1577058OtherAETNA HMO
NY7378969OtherAETNA
NY9037U1OtherEMPIRE BCBS - RIVERHILL
NYP00715034OtherRAILROAD MEDICARE
NYP00715034OtherRAILROAD MEDICARE
NY12416DW561Medicare PIN
NY02902358Medicaid