Provider Demographics
NPI:1427198126
Name:YOUNG, GLENN (OD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
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 1:550 FOREST AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1769
Mailing Address - Country:US
Mailing Address - Phone:734-455-3340
Mailing Address - Fax:734-254-9230
Practice Address - Street 1:550 FOREST AVE STE 12
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1769
Practice Address - Country:US
Practice Address - Phone:734-455-3340
Practice Address - Fax:734-254-9230
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003268152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU27552Medicare UPIN