Healthcare Provider Details

I. General information

NPI: 1194859926
Provider Name (Legal Business Name): JOHN L YOUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 MEXICO RD SUITE H
SAINT PETERS MO
63376-6414
US

IV. Provider business mailing address

14 REDGATE CT
SILVER SPRING MD
20905-5726
US

V. Phone/Fax

Practice location:
  • Phone: 301-989-0548
  • Fax:
Mailing address:
  • Phone: 301-989-0548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2012008874
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: