Healthcare Provider Details

I. General information

NPI: 1962545194
Provider Name (Legal Business Name): BEVERLY YOUNG O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 NEWPARK MALL
NEWARK CA
94560-5246
US

IV. Provider business mailing address

201 E GRANT LINE RD #14
TRACY CA
95376-2763
US

V. Phone/Fax

Practice location:
  • Phone: 510-790-1001
  • Fax: 510-790-1704
Mailing address:
  • Phone: 209-832-7839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9185
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: