Healthcare Provider Details

I. General information

NPI: 1275672206
Provider Name (Legal Business Name): TODD BENJAMIN YOUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 HIGH BLUFF DR STE 111
SAN DIEGO CA
92130-2053
US

IV. Provider business mailing address

12625 HIGH BLUFF DR STE 111
SAN DIEGO CA
92130-2053
US

V. Phone/Fax

Practice location:
  • Phone: 760-452-9027
  • Fax:
Mailing address:
  • Phone: 760-452-9027
  • Fax: 760-452-9037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA 107905
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA 107905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: