Provider Demographics
NPI:1376543108
Name:YOUNG, PETER S
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:S
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E BELL RD
Mailing Address - Street 2:STE 2200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2139
Mailing Address - Country:US
Mailing Address - Phone:602-633-3848
Mailing Address - Fax:602-633-3841
Practice Address - Street 1:10815 W MCDOWELL RD STE 305
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5016
Practice Address - Country:US
Practice Address - Phone:623-936-3312
Practice Address - Fax:623-936-4248
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26395207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110222436OtherRAILROAD MEDICARE
110222436OtherRAILROAD MEDICARE
E57524Medicare UPIN