Healthcare Provider Details

I. General information

NPI: 1912009234
Provider Name (Legal Business Name): VINCENT MICHAEL YOUNG OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 S. MAIN
BLANCHARD OK
73010-8003
US

IV. Provider business mailing address

PO BOX 325
BLANCHARD OK
73010-0325
US

V. Phone/Fax

Practice location:
  • Phone: 405-485-3937
  • Fax: 405-485-3642
Mailing address:
  • Phone: 405-485-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2441
License Number StateOK

VIII. Authorized Official

Name: DR. VINCENT MICHAEL YOUNG
Title or Position: OWNER
Credential: O.D.
Phone: 405-485-3937