=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952389520
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MASON L YOUNG OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2006
-----------------------------------------------------
Last Update Date | 10/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 W 4TH ST
-----------------------------------------------------
City | CORNING
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72422-2724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-857-2020
-----------------------------------------------------
Fax | 870-857-2022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 W 4TH ST
-----------------------------------------------------
City | CORNING
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72422-2724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-857-2020
-----------------------------------------------------
Fax | 870-857-2022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2536
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------