Healthcare Provider Details

I. General information

NPI: 1770515868
Provider Name (Legal Business Name): WALTER CLARK YOUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 ROSS CLARK CIR SUITE 600
DOTHAN AL
36301-3007
US

IV. Provider business mailing address

1118 ROSS CLARK CIR SUITE 600
DOTHAN AL
36301-3007
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-3900
  • Fax: 334-793-5227
Mailing address:
  • Phone: 334-793-3900
  • Fax: 334-793-5227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number11768
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number15444
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number24486
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number44986
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: