Provider Demographics
NPI:1962582221
Name:DR. ROBERT JACKSON YOUNG III
Entity type:Organization
Organization Name:DR. ROBERT JACKSON YOUNG III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-289-8972
Mailing Address - Street 1:204 MAGDALEN SQUARE
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70510
Mailing Address - Country:US
Mailing Address - Phone:337-289-8970
Mailing Address - Fax:337-289-8970
Practice Address - Street 1:204 MAGDALEN SQUARE
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70510
Practice Address - Country:US
Practice Address - Phone:337-289-8970
Practice Address - Fax:337-289-8970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5J537Medicare PIN