1811003593 NPI number — DR. SAMUEL DOAK YOUNG III MD

Table of content: (NPI 1881224160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811003593 NPI number — DR. SAMUEL DOAK YOUNG III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
SAMUEL
Provider Middle Name:
DOAK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YOUNG
Provider Other First Name:
SAMUEL
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
III
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1811003593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2080 CHILD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32214-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-542-7679
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2080 CHILD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32214-5005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-542-7679
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  ME96716 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 0101240022 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: ME96716 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: 2005-00921 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2762374-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 813042151A , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: NC1999 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1811003593 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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