Healthcare Provider Details

I. General information

NPI: 1528068350
Provider Name (Legal Business Name): DERICK WAYNE YOUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 39TH ST
GROVES TX
77619-2911
US

IV. Provider business mailing address

5301 39TH ST
GROVES TX
77619-2911
US

V. Phone/Fax

Practice location:
  • Phone: 409-962-4272
  • Fax: 409-962-2451
Mailing address:
  • Phone: 409-962-4272
  • Fax: 409-962-2451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL1502
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: