Provider Demographics
NPI:1689676009
Name:YOUNG, GREGORY GIRARD (DPM)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:GIRARD
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 1:1919 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6610
Mailing Address - Country:US
Mailing Address - Phone:910-763-9334
Mailing Address - Fax:910-763-9339
Practice Address - Street 1:1919 S 16TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6610
Practice Address - Country:US
Practice Address - Phone:910-763-9334
Practice Address - Fax:910-763-9339
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC262213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0817CMedicaid
NC890265NMedicaid
NC243141Medicare PIN
NC243141AMedicare ID - Type Unspecified
NC0552350001Medicare NSC
NCT64096Medicare UPIN