Provider Demographics
NPI:1548472467
Name:YOUNGBLOOD, ROBERT W (DC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 W MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-3148
Mailing Address - Country:US
Mailing Address - Phone:662-844-0640
Mailing Address - Fax:
Practice Address - Street 1:2434 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-3148
Practice Address - Country:US
Practice Address - Phone:662-844-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSU67697Medicare UPIN