Basic Information
| Provider Information | |||||||||
| NPI: | 1417953381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 DOCTORS PARK DR | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417791300 | ||||||||
| FaxNumber: | 5417799171 | ||||||||
| Practice Location | |||||||||
| Address1: | 2940 DOCTORS PARK DR | ||||||||
| Address2: | CHILDREN AND ADOLESCENTS CLINIC | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417791300 | ||||||||
| FaxNumber: | 5417799171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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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 | 208000000X | MD22188 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 138148 | 05 | OR | MEDICAID |