Provider Demographics
NPI:1285752824
Name:JERRY D. YOUNG, D.O., P.A.
Entity type:Organization
Organization Name:JERRY D. YOUNG, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:979-244-1317
Mailing Address - Street 1:PO BOX 203059
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-3059
Mailing Address - Country:US
Mailing Address - Phone:979-244-1317
Mailing Address - Fax:979-244-8993
Practice Address - Street 1:740 12TH ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-2904
Practice Address - Country:US
Practice Address - Phone:979-244-1317
Practice Address - Fax:979-244-8993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2011-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4630208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y859OtherMEDICARE ID - TYPE UNSPECIFIED
TX122021202Medicaid
TX122021202Medicaid