Healthcare Provider Details

I. General information

NPI: 1063647071
Provider Name (Legal Business Name): CLETE B YOUNGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 5TH AVE SE SUITE 1400
CEDAR RAPIDS IA
52403-2464
US

IV. Provider business mailing address

1030 5TH AVE SE SUITE 1400
CEDAR RAPIDS IA
52403-2464
US

V. Phone/Fax

Practice location:
  • Phone: 319-363-8121
  • Fax: 319-365-1396
Mailing address:
  • Phone: 319-363-8121
  • Fax: 319-365-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR-8608
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39083
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1063647071
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
IdentifierP01090381
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerRR MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: