Provider Demographics
NPI:1952480683
Name:YOUNG, ROGER (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 GROSBEAK CT
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-7511
Mailing Address - Country:US
Mailing Address - Phone:916-704-8770
Mailing Address - Fax:
Practice Address - Street 1:3325 GROSBEAK CT
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-7511
Practice Address - Country:US
Practice Address - Phone:916-704-8770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2020-0253207R00000X
WY13658C208M00000X
CAG61175208M00000X
ORMD214143207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G611750Medicaid
00G611750Medicare ID - Type Unspecified
CA00G611750Medicaid