Healthcare Provider Details

I. General information

NPI: 1487724258
Provider Name (Legal Business Name): MICHAEL O YOUNG OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6424 W JEFFERSON BLVD SUITE A
FORT WAYNE IN
46804-6204
US

IV. Provider business mailing address

6424 W JEFFERSON BLVD SUITE A
FORT WAYNE IN
46804-6204
US

V. Phone/Fax

Practice location:
  • Phone: 260-969-1400
  • Fax: 260-969-0322
Mailing address:
  • Phone: 260-969-1400
  • Fax: 260-969-0322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002134A
License Number StateIN

VIII. Authorized Official

Name: MICHAEL OWEN YOUNG
Title or Position: PRESIDENT
Credential: OD
Phone: 260-969-1400