=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982604047
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY MICHAEL YOUNG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1080 EMELINE AVE
-----------------------------------------------------
City | SANTA CRUZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95060-1966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-454-4100
-----------------------------------------------------
Fax | 831-454-5001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1080 EMELINE AVE CLINIC ADMIN
-----------------------------------------------------
City | SANTA CRUZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95060-1966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-454-4100
-----------------------------------------------------
Fax | 831-454-5001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | G52682
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------