=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427024074
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES R YOUNG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2006
-----------------------------------------------------
Last Update Date | 05/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 RUSSELL BLVD
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75965-1240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-559-9019
-----------------------------------------------------
Fax | 936-462-7876
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 632189
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75963-2189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-559-9019
-----------------------------------------------------
Fax | 936-462-7876
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | K4616
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------