Provider Demographics
NPI:1972663946
Name:YOUNG, JOHN VINCENT JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:VINCENT
Last Name:YOUNG
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8106 E CHAMPIONS ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-3324
Mailing Address - Country:US
Mailing Address - Phone:410-336-6773
Mailing Address - Fax:410-427-5511
Practice Address - Street 1:8106 E CHAMPIONS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-3324
Practice Address - Country:US
Practice Address - Phone:410-336-6773
Practice Address - Fax:410-427-5511
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS435332208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP01024270OtherRR MEDICARE
OR113621Medicaid
KS200750860AMedicaid
ORR116986Medicare PIN
KS200750860AMedicaid
ORC94139Medicare UPIN
KSKA2273009Medicare UPIN