Provider Demographics
NPI:1912953852
Name:YOUNG, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:YOUNG
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:PO BOX 4078
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4078
Mailing Address - Country:US
Mailing Address - Phone:888-633-0086
Mailing Address - Fax:
Practice Address - Street 1:1255 HILYARD ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3718
Practice Address - Country:US
Practice Address - Phone:541-686-6932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12211207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR077862Medicaid
WA8280158Medicaid
A019OtherCHAMPUS
057221008OtherBCBS
D70722OtherPROVIDENCE
CAXPY187524Medicaid
104999OtherWA L & I
D70722OtherGROUP HEALTH
D70722OtherLIPA
0000WFBBXMedicare PIN
D70722OtherLIPA
D70722OtherGROUP HEALTH
A019OtherCHAMPUS
CAXPY187524Medicaid