Provider Demographics
NPI:1386615342
Name:YOUNG-GOMERMAN, WENDY R (DPM)
Entity type:Individual
Prefix:DR
First Name:WENDY
Middle Name:R
Last Name:YOUNG-GOMERMAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-689-8333
Mailing Address - Fax:
Practice Address - Street 1:222 E MIDDLE COUNTRY RD STE 209
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2814
Practice Address - Country:US
Practice Address - Phone:631-638-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005265213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU62331Medicare UPIN
NY4973700001Medicare NSC
NYP67562Medicare PIN