Provider Demographics
NPI:1528068350
Name:YOUNG, DERICK WAYNE (MD)
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:WAYNE
Last Name:YOUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 39TH ST
Mailing Address - Street 2:
Mailing Address - City:GROVES
Mailing Address - State:TX
Mailing Address - Zip Code:77619-2911
Mailing Address - Country:US
Mailing Address - Phone:409-962-4272
Mailing Address - Fax:409-962-2451
Practice Address - Street 1:5301 39TH ST
Practice Address - Street 2:
Practice Address - City:GROVES
Practice Address - State:TX
Practice Address - Zip Code:77619-2911
Practice Address - Country:US
Practice Address - Phone:409-962-4272
Practice Address - Fax:409-962-2451
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144036402OtherWELLMED MEDICAID
TXTXB124736OtherWELLMED MEDICARE
H38767Medicare UPIN
TX144036402OtherWELLMED MEDICAID