Healthcare Provider Details

I. General information

NPI: 1356674519
Provider Name (Legal Business Name): KIM SAMUEL YOUNG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2009
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6349 US HWY 550
CUBA NM
87013-0638
US

IV. Provider business mailing address

PO BOX 2267
SANTA FE NM
87504-2267
US

V. Phone/Fax

Practice location:
  • Phone: 575-289-3291
  • Fax: 505-722-7470
Mailing address:
  • Phone: 59-825-5655
  • Fax: 505-992-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4023
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA-1267-04
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0031167
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: