Provider Demographics
NPI:1528187838
Name:YOUNG, DEATRA L (MD)
Entity Type:Individual
Prefix:
First Name:DEATRA
Middle Name:L
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 SPECTRUM DR
Mailing Address - Street 2:SUITE 1200 WEST
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4648
Mailing Address - Country:US
Mailing Address - Phone:972-364-8000
Mailing Address - Fax:
Practice Address - Street 1:11700 METRO AIRPORT CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-1456
Practice Address - Country:US
Practice Address - Phone:615-778-4066
Practice Address - Fax:615-778-9114
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010605892083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1504020Medicare UPIN
MIMI1503020Medicare UPIN
MIMI1504Medicare PIN
MIMI1503Medicare PIN