Basic Information
| Provider Information | |||||||||
| NPI: | 1861599847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 122152 DEPT 2152 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753122152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374942921 | ||||||||
| FaxNumber: | 3374946523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 OAK PARK BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374943278 | ||||||||
| FaxNumber: | 3374943240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 12469R | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | MD.12469R | 01 | LA | STATE LICENSE | OTHER | 1535893 | 05 | LA | MEDICAID |