Provider Demographics
NPI:1689665630
Name:YOUNG, ROGER WAYNE (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:WAYNE
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 1:8700 CENTRAL MALL DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-8058
Mailing Address - Country:US
Mailing Address - Phone:409-722-6141
Mailing Address - Fax:409-724-2405
Practice Address - Street 1:8700 CENTRAL MALL DRIVE
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-8058
Practice Address - Country:US
Practice Address - Phone:409-722-6141
Practice Address - Fax:409-724-2405
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3548T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83048EMedicare PIN
TXT91208Medicare UPIN