Healthcare Provider Details

I. General information

NPI: 1790105518
Provider Name (Legal Business Name): KRISTEN YOUNG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2014
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 S MAIN ST STE 200
CENTERVILLE OH
45458-4358
US

IV. Provider business mailing address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

V. Phone/Fax

Practice location:
  • Phone: 937-436-3117
  • Fax: 937-436-0730
Mailing address:
  • Phone: 937-762-1310
  • Fax: 937-522-8068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR0056005
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM13533
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-13533
License Number StateID
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.147511
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: