Provider Demographics
NPI:1780772434
Name:YOUNGSTROM, CARL (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:YOUNGSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 CASTLEVALE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-7807
Mailing Address - Country:US
Mailing Address - Phone:509-575-7652
Mailing Address - Fax:509-575-3658
Practice Address - Street 1:3911 CASTLEVALE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-7807
Practice Address - Country:US
Practice Address - Phone:509-575-7652
Practice Address - Fax:509-575-3658
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014591208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7017049Medicaid
WA7017049Medicaid