Provider Demographics
NPI:1295396257
Name:YOUNGBLOOD, SYLVIANNE (OD)
Entity Type:Individual
Prefix:
First Name:SYLVIANNE
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 4TH ST STE 440
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6241
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:
Practice Address - Street 1:6209 CHAPEL HILL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8488
Practice Address - Country:US
Practice Address - Phone:972-378-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60947784152W00000X
TX10505T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist