=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710514344
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAKE YOUNG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2020
-----------------------------------------------------
Last Update Date | 05/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3811 SAGEBRIAR DR
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-6107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-774-0498
-----------------------------------------------------
Fax | 979-774-7673
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3811 SAGEBRIAR DR
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-6107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-774-0498
-----------------------------------------------------
Fax | 979-774-7673
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | BP20076833
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------