Provider Demographics
NPI:1285858936
Name:YOUNG, LAWRENCE EDWIN (O D)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:EDWIN
Last Name:YOUNG
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10004 SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6723
Mailing Address - Country:US
Mailing Address - Phone:909-822-6941
Mailing Address - Fax:909-822-3985
Practice Address - Street 1:10004 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6723
Practice Address - Country:US
Practice Address - Phone:909-822-6941
Practice Address - Fax:909-822-3985
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8618T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0086180Medicaid
CAU52663Medicare UPIN
CASD0086180Medicaid