Provider Demographics
NPI:1417964792
Name:YOUNG, THOMAS A (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
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 1:211 E HAVENS ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-4402
Mailing Address - Country:US
Mailing Address - Phone:605-996-4671
Mailing Address - Fax:605-996-4671
Practice Address - Street 1:211 E HAVENS ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-4402
Practice Address - Country:US
Practice Address - Phone:605-996-4671
Practice Address - Fax:605-996-4671
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD451152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDP00849313OtherRAILROAD MEDICARE
SD0076548OtherBLUE CROSS BLUE SHIELD
SD0530030001OtherDMERC
SD4266OtherAVERA HEALTH PLANS
SD9201890Medicaid
SDS103751Medicare PIN
SD0076548OtherBLUE CROSS BLUE SHIELD