Healthcare Provider Details

I. General information

NPI: 1619939147
Provider Name (Legal Business Name): DAVID C YOUNG SUB IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 NIDER BOULEVARD NAVAL AMPHIBIOUS BASE LITTLE CREEK SUITE 100
NORFOLK VA
23521-2731
US

IV. Provider business mailing address

1349 CALLA AVE
NORFOLK VA
23503-3054
US

V. Phone/Fax

Practice location:
  • Phone: 757-227-6192
  • Fax:
Mailing address:
  • Phone: 757-227-6192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: