Provider Demographics
NPI:1881664498
Name:YOUNG, LAWRENCE A (DPM)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:A
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 VINEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1311
Mailing Address - Country:US
Mailing Address - Phone:248-647-3832
Mailing Address - Fax:
Practice Address - Street 1:22161 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3901
Practice Address - Country:US
Practice Address - Phone:313-565-8080
Practice Address - Fax:313-565-2417
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1062616Medicaid
MIT97294Medicare UPIN
MI1062616Medicaid