Provider Demographics
NPI:1568425064
Name:YOUNG, TODD E (DO)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:E
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 12TH AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3926
Mailing Address - Country:US
Mailing Address - Phone:817-871-9069
Mailing Address - Fax:817-871-9067
Practice Address - Street 1:1001 12TH AVE STE 140
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3926
Practice Address - Country:US
Practice Address - Phone:817-871-9069
Practice Address - Fax:817-871-9067
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2389208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145824202Medicaid
TX145824203Medicaid
TX145824201Medicaid
TX8L4014Medicare PIN
TX145824203Medicaid
TXG85887Medicare UPIN
TX145824202Medicaid