Provider Demographics
NPI:1508830340
Name:YOUNG, JOHNNY SHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:SHAN
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 8061
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36202-8061
Mailing Address - Country:US
Mailing Address - Phone:256-435-1399
Mailing Address - Fax:256-435-1911
Practice Address - Street 1:409 E 10TH ST STE 300
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-4781
Practice Address - Country:US
Practice Address - Phone:256-435-1399
Practice Address - Fax:256-435-1911
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15920174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL00083944Medicaid
AL83944OtherBCBS PROVIDER
AL83944OtherBCBS PROVIDER