Provider Demographics
NPI:1881962652
Name:YOUNG, EVAN REESE (DPM)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:REESE
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 1:2511 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6301
Mailing Address - Country:US
Mailing Address - Phone:813-879-7850
Mailing Address - Fax:
Practice Address - Street 1:1005 DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-3021
Practice Address - Country:US
Practice Address - Phone:813-549-5678
Practice Address - Fax:813-701-9132
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4216213E00000X, 213EP1101X, 213ES0131X, 213ES0103X
IL135.000731213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108826400Medicaid
FLISELDOtherBCBS
14953569OtherCAQH ID
FL4790067OtherAETNA ID
FL8672007OtherCIGNA ID