Provider Demographics
NPI:1346504891
Name:YOUNG, STEPHENIE L (OD)
Entity Type:Individual
Prefix:
First Name:STEPHENIE
Middle Name:L
Last Name:YOUNG
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 1:942 N HOYNE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4903
Mailing Address - Country:US
Mailing Address - Phone:517-230-5871
Mailing Address - Fax:
Practice Address - Street 1:3123 N BROADWAY ST STE A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4522
Practice Address - Country:US
Practice Address - Phone:773-880-5400
Practice Address - Fax:773-880-5406
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010569152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010569Medicaid
IL502720057OtherMEDICARE PTAN