Healthcare Provider Details

I. General information

NPI: 1700816709
Provider Name (Legal Business Name): JON RANDAL YOUNG DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 S. REDWOOD ROAD SUITE B
SALT LAKE CITY UT
84123-2223
US

IV. Provider business mailing address

4370 S. REDWOOD ROAD SUITE B
SALT LAKE CITY UT
84123-2223
US

V. Phone/Fax

Practice location:
  • Phone: 801-417-5386
  • Fax: 801-417-5522
Mailing address:
  • Phone: 801-417-5386
  • Fax: 801-417-5522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number104424-0501
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number104424-0501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: