1417964792 NPI number — DR. THOMAS A YOUNG O.D.

Table of content: DR. THOMAS A YOUNG O.D. (NPI 1417964792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417964792 NPI number — DR. THOMAS A YOUNG O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
THOMAS
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417964792
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 E HAVENS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MITCHELL
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57301-4402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-996-4671
Provider Business Mailing Address Fax Number:
605-996-4671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 E HAVENS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MITCHELL
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57301-4402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-996-4671
Provider Business Practice Location Address Fax Number:
605-996-4671
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  451 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00849313 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0076548 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0530030001 . This is a "DMERC" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 4266 . This is a "AVERA HEALTH PLANS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9201890 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com