Provider Demographics
NPI:1043380819
Name:YOUNG, MICHAEL OWEN (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:OWEN
Last Name:YOUNG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6424 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6204
Mailing Address - Country:US
Mailing Address - Phone:260-436-7530
Mailing Address - Fax:260-436-2698
Practice Address - Street 1:6424 W JEFFERSON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6204
Practice Address - Country:US
Practice Address - Phone:260-436-7530
Practice Address - Fax:260-436-2698
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002134A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
18808OtherSPECTERA
IN2134OtherEYEMED
18808OtherSPECTERA