Basic Information
| Provider Information | |||||||||
| NPI: | 1982604047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 EMELINE AVE | ||||||||
| Address2: | CLINIC ADMIN | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544100 | ||||||||
| FaxNumber: | 8314545001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1080 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544100 | ||||||||
| FaxNumber: | 8314545001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 10/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | G52682 | CA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | AY2766674 | 01 | DEA | OTHER |