Healthcare Provider Details

I. General information

NPI: 1992091748
Provider Name (Legal Business Name): EDWIN ARTHUR YOUNGSTROM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 SAN DIMAS ST STE B231
BAKERSFIELD CA
93301-1494
US

IV. Provider business mailing address

3838 SAN DIMAS ST STE B231
BAKERSFIELD CA
93301-1494
US

V. Phone/Fax

Practice location:
  • Phone: 661-665-0505
  • Fax: 661-665-7844
Mailing address:
  • Phone: 661-665-0505
  • Fax: 661-665-7844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number5101019533
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: