Provider Demographics
NPI:1437135217
Name:YOUNG, JOSEPH THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:THEODORE
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:PO BOX 4297
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80306-4297
Mailing Address - Country:US
Mailing Address - Phone:303-518-1931
Mailing Address - Fax:
Practice Address - Street 1:1015 BOWLES AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026
Practice Address - Country:US
Practice Address - Phone:636-496-2000
Practice Address - Fax:314-996-1681
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3008207P00000X
CO23542207P00000X
CAC50185207P00000X
MO2008028220207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00691434OtherRR MEDICARE INDIVIDUAL PTAN NUMBER
CO01235423Medicaid
COD42956Medicare UPIN
MO145740003Medicare PIN
COE50226Medicare ID - Type Unspecified