Healthcare Provider Details

I. General information

NPI: 1013422401
Provider Name (Legal Business Name): YOUNG EYE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12325 N ROCKWELL AVE
OKLAHOMA CITY OK
73142-2702
US

IV. Provider business mailing address

12325 N ROCKWELL AVE
OKLAHOMA CITY OK
73142-2702
US

V. Phone/Fax

Practice location:
  • Phone: 405-728-3393
  • Fax:
Mailing address:
  • Phone: 405-728-3393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2117
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2117
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number2117
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number2117
License Number StateOK

VIII. Authorized Official

Name: DR. GARY PATRICK YOUNG
Title or Position: DOCTOR / OWNER
Credential: OD
Phone: 405-728-3393