Healthcare Provider Details

I. General information

NPI: 1972580066
Provider Name (Legal Business Name): MARK R YOUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 N 1ST ST
INDIANOLA IA
50125-3702
US

IV. Provider business mailing address

1504 N 1ST ST
INDIANOLA IA
50125-3702
US

V. Phone/Fax

Practice location:
  • Phone: 515-961-3700
  • Fax: 515-962-0160
Mailing address:
  • Phone: 515-961-3700
  • Fax: 515-962-0160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24278
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: