Provider Demographics
NPI:1629140397
Name:DEYOUNG, JOHN G JR (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:DEYOUNG
Suffix:JR
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 1:150 S FAIRLANE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3647
Mailing Address - Country:US
Mailing Address - Phone:630-782-2037
Mailing Address - Fax:
Practice Address - Street 1:41 TOWN SQ
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3829
Practice Address - Country:US
Practice Address - Phone:630-681-0228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU36154Medicare UPIN
ILL77658Medicare ID - Type Unspecified