Healthcare Provider Details

I. General information

NPI: 1851736045
Provider Name (Legal Business Name): JOHN L. YOUNG, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 05/02/2013
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: 301-989-1543
Mailing address:
  • Phone: 301-989-0548
  • Fax: 301-989-1543

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: DR. JOHN L YOUNG
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 301-989-0548