Provider Demographics
NPI:1386771954
Name:YOUNG, MARY JO (MD)
Entity type:Individual
Prefix:DR
First Name:MARY JO
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:HOLY CROSS MEDICAL CENTER PRIMARY CARE CLINIC
Mailing Address - Street 2:1329 GUSDORF ROAD
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:575-737-3415
Mailing Address - Fax:575-737-3416
Practice Address - Street 1:HOLY CROSS MEDICAL CENTER PRIMARY CARE CLINIC
Practice Address - Street 2:1329 GUSDORF ROAD
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-737-3416
Practice Address - Fax:575-737-3416
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2023-11-07
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Provider Licenses
StateLicense IDTaxonomies
NMMD2023-1249207R00000X
CO37019207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95673768Medicaid
CO95673768Medicaid
COC482948Medicare PIN
COG91046Medicare UPIN