Provider Demographics
NPI:1174673727
Name:HARRIS R.YOUNG,O.D.
Entity Type:Organization
Organization Name:HARRIS R.YOUNG,O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:707-576-1961
Mailing Address - Street 1:1311 W STEELE LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2956
Mailing Address - Country:US
Mailing Address - Phone:707-576-1961
Mailing Address - Fax:707-576-1036
Practice Address - Street 1:1311 W STEELE LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2956
Practice Address - Country:US
Practice Address - Phone:707-576-1961
Practice Address - Fax:707-576-1036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7395T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADS4522OtherRAILROAD MEDICARE
CADS4522OtherRAILROAD MEDICARE
CADS4522OtherRAILROAD MEDICARE
CAZZZ30073ZMedicare PIN
CAT10527Medicare UPIN
CA0192950001Medicare NSC