Provider Demographics
NPI:1649280256
Name:YOUNG, GERALD L (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:L
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 1:366 S 3RD W
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276-1559
Mailing Address - Country:US
Mailing Address - Phone:208-547-4961
Mailing Address - Fax:208-547-3781
Practice Address - Street 1:366 S 3RD W
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276-1559
Practice Address - Country:US
Practice Address - Phone:208-547-4961
Practice Address - Fax:208-547-3781
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0025019Medicaid
ID080191334OtherRAILROAD MEDICARE
ID000010006157OtherREGENCE BLUE SHIELD
ID32342OtherBLUE CROSS OF IDAHO
ID080191334OtherRAILROAD MEDICARE
ID0025019Medicaid