Provider Demographics
NPI:1518948587
Name:YOUNG, RICHARD W (DR)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:823 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-449-1010
Practice Address - Fax:843-497-6171
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD16508208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC340011956OtherRAILROAD MEDICARE
SCP00360569OtherRAILROAD MEDICARE
SC165083Medicaid
SC773672OtherWELLCARE
NC890562QMedicaid
SCGP1418Medicaid
SCGP4522Medicaid
SCF183425107Medicare ID - Type Unspecified
SC165083Medicaid
SCF183428568Medicare PIN