Basic Information
| Provider Information | |||||||||
| NPI: | 1154338226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE YOUNG | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| OtherLastName: | DE YOUNG | ||||||||
| OtherFirstName: | BOB | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 840207 | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330842207 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1613 HARRISON PKWY | ||||||||
| Address2: | #200 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548382371 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 11/09/2010 | ||||||||
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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 | 207L00000X | ME19435 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 046958100 | 05 | FL | MEDICAID |