Provider Demographics
NPI:1003498296
Name:YOUNG, CONNOR DAVID (OD)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:DAVID
Last Name:YOUNG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:804 BROAD RIPPLE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-1961
Practice Address - Country:US
Practice Address - Phone:317-257-5421
Practice Address - Fax:317-257-4086
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
IN18004269A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program