Healthcare Provider Details

I. General information

NPI: 1013910744
Provider Name (Legal Business Name): ROBERT P YOUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 08/18/2018
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/29/2006

III. Provider practice location address

1760 N 200 E STE 101
NORTH LOGAN UT
84341
US

IV. Provider business mailing address

1760 N 200 E STE 101
NORTH LOGAN UT
84341-1202
US

V. Phone/Fax

Practice location:
  • Phone: 435-787-0560
  • Fax:
Mailing address:
  • Phone: 435-787-0560
  • Fax: 435-752-4673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number295172-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number295172-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number295172-1205
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number295172-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: