Healthcare Provider Details

I. General information

NPI: 1104998194
Provider Name (Legal Business Name): THOMAS R YOUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 RESERVOIR DRIVE SUITE 112
SAN DIEGO CA
92120-5195
US

IV. Provider business mailing address

5555 RESERVOIR DRIVE SUITE 112
SAN DIEGO CA
92120-5195
US

V. Phone/Fax

Practice location:
  • Phone: 619-287-7060
  • Fax: 619-287-7078
Mailing address:
  • Phone: 619-287-7060
  • Fax: 619-287-7078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberG69189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: