Provider Demographics
NPI:1235221219
Name:YOUNG, MARVIN JASON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:JASON
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 1:1071 S SUN DR
Mailing Address - Street 2:SUITE 1003
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2405
Mailing Address - Country:US
Mailing Address - Phone:407-302-2620
Mailing Address - Fax:407-302-2690
Practice Address - Street 1:1071 S SUN DR
Practice Address - Street 2:SUITE 1003
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2405
Practice Address - Country:US
Practice Address - Phone:407-302-2620
Practice Address - Fax:407-302-2690
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80601208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000105000Medicaid
FLME80601OtherSTATE LICENSE #
FLPTAN# DO3210OtherRR MEDICARE
FLGROUP # 000354800Medicaid
FLGROUP # 000354800Medicaid
FLPTAN# DO3210OtherRR MEDICARE
FLH22606Medicare UPIN
FLPTAN# DO3210OtherRR MEDICARE