Basic Information
| Provider Information | |||||||||
| NPI: | 1649288895 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349950417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722235665 | ||||||||
| FaxNumber: | 7722235646 | ||||||||
| Practice Location | |||||||||
| Address1: | 1651 SE TIFFANY AVE | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349527564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723981800 | ||||||||
| FaxNumber: | 7723981815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME40258 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 067073100 | 05 | FL | MEDICAID |