Provider Demographics
NPI:1528261567
Name:YOUNG, LANCELOT JBG (MD)
Entity type:Individual
Prefix:DR
First Name:LANCELOT
Middle Name:JBG
Last Name:YOUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1640
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-0900
Mailing Address - Country:US
Mailing Address - Phone:516-872-8600
Mailing Address - Fax:516-594-0656
Practice Address - Street 1:474 MCDERMOTT RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1426
Practice Address - Country:US
Practice Address - Phone:516-872-8600
Practice Address - Fax:516-594-0656
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY142854207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01020199Medicaid
NYA60053Medicare UPIN