Provider Demographics
NPI:1124119631
Name:YOUNGTAN, ALISON M (MD)
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:M
Last Name:YOUNGTAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 GOLFVIEW AVE
Mailing Address - Street 2:ATTN: ACCOUNTS RECEIVABLE
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-6740
Mailing Address - Country:US
Mailing Address - Phone:863-519-7900
Mailing Address - Fax:863-519-7696
Practice Address - Street 1:3241 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2266
Practice Address - Country:US
Practice Address - Phone:863-413-2620
Practice Address - Fax:863-499-2612
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079456207R00000X
FLME103086207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004522400Medicaid
FL14L1NOtherBCBS
OH2583100Medicaid
FLGH017ZMedicare PIN
FL14L1NOtherBCBS
OHH88000Medicare UPIN