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General NPI Number Information
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NPI Number | 1487724258
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Entity Type | Organization
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Legal Business Name | MICHAEL O YOUNG OD PC
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 11/28/2012
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Provider Practice Location Address
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Address Line | 6424 W JEFFERSON BLVD SUITE A
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City | FORT WAYNE
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State | IN
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Zip | 46804-6204
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Country | US
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Telephone | 260-969-1400
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Fax | 260-969-0322
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Provider Business Mailing Address
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Address Line | 6424 W JEFFERSON BLVD SUITE A
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City | FORT WAYNE
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State | IN
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Zip | 46804-6204
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Country | US
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Telephone | 260-969-1400
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Fax | 260-969-0322
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL OWEN YOUNG
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Credential | OD
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Telephone | 260-969-1400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 18002134A
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License Number State | IN
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