Healthcare Provider Details

I. General information

NPI: 1710984422
Provider Name (Legal Business Name): TIMOTHY YOUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 EMERSON ST STE A
CLEARLAKE CA
95422-9529
US

IV. Provider business mailing address

3400 EMERSON ST STE A
CLEARLAKE CA
95422-9529
US

V. Phone/Fax

Practice location:
  • Phone: 707-995-4155
  • Fax: 707-995-4158
Mailing address:
  • Phone: 707-995-4155
  • Fax: 707-995-4158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA41608
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: