Provider Demographics
NPI:1811375199
Name:YOUNG, DIANA STARR (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:STARR
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9696
Mailing Address - Fax:239-343-4198
Practice Address - Street 1:8960 COLONIAL CENTER DR STE 206
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7810
Practice Address - Country:US
Practice Address - Phone:239-343-9696
Practice Address - Fax:239-343-4198
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2022-02-16
Deactivation Date:2015-11-10
Deactivation Code:
Reactivation Date:2016-08-03
Provider Licenses
StateLicense IDTaxonomies
CA152141207X00000X
FLME152394207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018528600Medicaid
FL7H6ATOtherBCBS
FLIR494ZMedicare PIN