Provider Demographics
NPI:1700816709
Name:YOUNG, JON RANDAL (DPM)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:RANDAL
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4370 S. REDWOOD ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-2223
Mailing Address - Country:US
Mailing Address - Phone:801-417-5386
Mailing Address - Fax:801-417-5522
Practice Address - Street 1:4370 S. REDWOOD ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-2223
Practice Address - Country:US
Practice Address - Phone:801-417-5386
Practice Address - Fax:801-417-5522
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT104424-0501213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5572070001Medicare NSC