Provider Demographics
NPI:1437130366
Name:YOUNG, EDWIN R (DO)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:R
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-6490
Practice Address - Street 1:489 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-5709
Practice Address - Country:US
Practice Address - Phone:508-832-9646
Practice Address - Fax:508-832-7862
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3042464Medicaid
MAJ08051Medicare ID - Type Unspecified
MA3042464Medicaid