Basic Information
| Provider Information | |||||||||
| NPI: | 1528008646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177597000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1450 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177028300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | N3403 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2037335-03 | 05 | TX | MEDICAID | P00979876 | 01 | TX | RAILROAD MEDICARE | OTHER | 2037335-04 | 05 | TX | MEDICAID | 8CV082 | 01 | BCBS | OTHER |