Provider Demographics
NPI:1588684765
Name:YOUNG, STEPHEN GRANVILLE (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:GRANVILLE
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-825-4934
Mailing Address - Fax:310-206-0865
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:#365,530,420,120
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-4997
Practice Address - Fax:310-206-0865
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2010-06-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG41166207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G411660Medicaid
CAWG41166AMedicare PIN
CAA48479Medicare UPIN