Provider Demographics
NPI:1124184031
Name:YOUNG, MOSES (MD)
Entity Type:Individual
Prefix:DR
First Name:MOSES
Middle Name:
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 1:106 BRANDI LN
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-7416
Mailing Address - Country:US
Mailing Address - Phone:601-786-3475
Mailing Address - Fax:601-786-9980
Practice Address - Street 1:225 COMMUNITY DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069
Practice Address - Country:US
Practice Address - Phone:601-786-3475
Practice Address - Fax:601-786-9980
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12329207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0015034Medicaid
110000718Medicare ID - Type Unspecified
MS0015034Medicaid