Provider Demographics
NPI:1831340462
Name:YOUNG, MATTHEW LAYNE (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LAYNE
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12730 NEW BRITTANY BLVD STE 602
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4690
Mailing Address - Country:US
Mailing Address - Phone:239-275-5522
Mailing Address - Fax:239-275-4464
Practice Address - Street 1:7381 COLLEGE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5527
Practice Address - Country:US
Practice Address - Phone:239-482-1010
Practice Address - Fax:239-481-1481
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10574207Q00000X
FLOS16177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01282516/ DU4034OtherRAILROAD MEDICARE-ADELANTO
CAP01324740/ DU5182OtherRAILROAD MEDICARE-VICTORVILLE
CAEFF: 10/5/2012Medicaid
CADD440XMedicare PIN
CAP01282516Medicare PIN
CACA114410Medicare PIN
CADD440YMedicare PIN