Healthcare Provider Details

I. General information

NPI: 1659310738
Provider Name (Legal Business Name): ANDREW GINN BONG YOUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOPPIN ST STE 202
PROVIDENCE RI
02903-4141
US

IV. Provider business mailing address

4 LA LINDA DR
LONG BEACH CA
90807-3306
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-6551
  • Fax:
Mailing address:
  • Phone: 310-415-3676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD16400
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberMD16400
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: