Provider Demographics
NPI:1093968117
Name:YOUNG, BARRY (DPM)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1069
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1069
Mailing Address - Country:US
Mailing Address - Phone:909-796-3707
Mailing Address - Fax:909-796-3709
Practice Address - Street 1:11332 MOUNTAIN VIEW AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3854
Practice Address - Country:US
Practice Address - Phone:909-796-3707
Practice Address - Fax:909-796-3709
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1961213E00000X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE1961OtherBOARD OF PODIATRIC MEDICINE