Provider Demographics
NPI:1689739005
Name:YOUNG, GREGORY J (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:YOUNG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6663
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:7300 DODGE ST STE 139
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3603
Practice Address - Country:US
Practice Address - Phone:402-391-1112
Practice Address - Fax:402-391-8011
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE788152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE279641Medicare ID - Type UnspecifiedOD PIN
NEU21324Medicare UPIN