Healthcare Provider Details

I. General information

NPI: 1982259628
Provider Name (Legal Business Name): SAMANTHA ANNIE YOUNG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20211 PATIO DR STE 100
CASTRO VALLEY CA
94546-4338
US

IV. Provider business mailing address

686 BLACK PINE DR
SAN LEANDRO CA
94577-1373
US

V. Phone/Fax

Practice location:
  • Phone: 510-881-4401
  • Fax: 510-881-4423
Mailing address:
  • Phone: 510-816-8835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34321TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: