Provider Demographics
NPI:1154302099
Name:YOUNG, MICHAEL DAVID (DPT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DPT
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 654
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-0028
Mailing Address - Country:US
Mailing Address - Phone:541-767-2750
Mailing Address - Fax:541-767-2751
Practice Address - Street 1:303 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2032
Practice Address - Country:US
Practice Address - Phone:541-767-2750
Practice Address - Fax:541-767-2751
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR264924Medicaid
OR132716Medicare ID - Type UnspecifiedMEDICARE NUMBER