Provider Demographics
NPI:1295725489
Name:YOUNGBERG, DEAN I (MD)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:I
Last Name:YOUNGBERG
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 1:1035 N EMPORIA ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2944
Mailing Address - Country:US
Mailing Address - Phone:316-268-6075
Mailing Address - Fax:316-291-7977
Practice Address - Street 1:1035 N EMPORIA ST
Practice Address - Street 2:SUITE 220
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2944
Practice Address - Country:US
Practice Address - Phone:316-268-6075
Practice Address - Fax:316-291-7977
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15539207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100092960AMedicaid
KS100092960AMedicaid
YOU003625Medicare ID - Type Unspecified