Healthcare Provider Details

I. General information

NPI: 1679832737
Provider Name (Legal Business Name): JORDAN T YOUNG MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9332 STATE ROAD 54 STE 202
TRINITY FL
34655-1810
US

IV. Provider business mailing address

9332 STATE ROAD 54 STE 202
TRINITY FL
34655-1810
US

V. Phone/Fax

Practice location:
  • Phone: 727-597-4441
  • Fax: 727-597-4445
Mailing address:
  • Phone: 727-597-4441
  • Fax: 727-597-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberME112761
License Number StateFL

VIII. Authorized Official

Name: JORDAN TERRELL YOUNG
Title or Position: PHYSICIAN
Credential: MD
Phone: 252-258-6375