Provider Demographics
NPI:1902899271
Name:YOUNG, LEO KL (MD)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:KL
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 1:116 DOBBS DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-1942
Mailing Address - Country:US
Mailing Address - Phone:704-880-0388
Mailing Address - Fax:336-679-6752
Practice Address - Street 1:116 DOBBS DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-1942
Practice Address - Country:US
Practice Address - Phone:704-880-0388
Practice Address - Fax:336-679-6752
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96-00787207Q00000X
NC9600787282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136N4Medicaid
NC89136N4Medicaid