Provider Demographics
NPI:1467491720
Name:YOUNG, CHARLES R (DPM)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21111 MIDDLEBELT RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5549
Mailing Address - Country:US
Mailing Address - Phone:248-478-1150
Mailing Address - Fax:248-478-1156
Practice Address - Street 1:21111 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5549
Practice Address - Country:US
Practice Address - Phone:248-478-1150
Practice Address - Fax:248-478-1156
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICY000630213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1064218Medicaid
MIU06345Medicare UPIN
MI1064218Medicaid