Basic Information
| Provider Information | |||||||||
| NPI: | 1306840772 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | YOUNG | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 SAN MARCO BLVD | ||||||||
| Address2: | SUITE 701 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463465 | ||||||||
| FaxNumber: | 9042417331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1577 ROBERTS DR | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322503264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042411204 | ||||||||
| FaxNumber: | 9042417331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME57493 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3704157-00 | 05 | FL | MEDICAID |