Healthcare Provider Details

I. General information

NPI: 1629008743
Provider Name (Legal Business Name): YOUNG JCO YOUN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 CRAIN HIGHWAY NORTH UNIT 5-A
GLEN BURNE MD
21061
US

IV. Provider business mailing address

1410 CRAIN HIGHWAY NORTH UNIT 5-A
GLEN BURNE MD
21061
US

V. Phone/Fax

Practice location:
  • Phone: 410-761-1424
  • Fax: 410-761-0301
Mailing address:
  • Phone: 410-761-1424
  • Fax: 410-761-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD22113
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: