Healthcare Provider Details

I. General information

NPI: 1801114384
Provider Name (Legal Business Name): IVAN YOUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2010
Last Update Date: 05/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 HUDSON ST GRD FLR
NEW YORK NY
10014-3669
US

IV. Provider business mailing address

395 HUDSON ST GROUND FLR
NEW YORK NY
10014-3669
US

V. Phone/Fax

Practice location:
  • Phone: 212-463-8605
  • Fax: 212-463-8579
Mailing address:
  • Phone: 212-463-8605
  • Fax: 212-463-8579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number173998
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: