=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235221219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARVIN JASON YOUNG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1071 S SUN DR SUITE 1003
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-302-2620
-----------------------------------------------------
Fax | 407-302-2690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1071 S SUN DR SUITE 1003
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-302-2620
-----------------------------------------------------
Fax | 407-302-2690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | ME80601
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------