Basic Information
| Provider Information | |||||||||
| NPI: | 1720081417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | RICHARD | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1830 DESTINY LN | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708463338 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1830 DESTINY LN | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708463338 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 11/11/2008 | ||||||||
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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 | 213E00000X | 230 | KY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0131X | 230 | KY | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | 80002306 | 05 | KY | MEDICAID | 90004391 | 01 | KY | MEDICAID DME | OTHER | 480029186 | 01 | KY | RAILROAD MEDICARE | OTHER |