Provider Demographics
NPI:1407854367
Name:YOUNG, MARTIN S (LPT)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:S
Last Name:YOUNG
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 OCKLEY DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3024
Mailing Address - Country:US
Mailing Address - Phone:318-617-4194
Mailing Address - Fax:
Practice Address - Street 1:241 OCKLEY DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-3024
Practice Address - Country:US
Practice Address - Phone:318-617-4194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1040277225100000X
LAPT-381225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1093213-01Medicaid
TX650276Medicare PIN