Provider Demographics
NPI:1811039407
Name:YOUNG, WALLACE HOWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:HOWARD
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 1:10426 BRIARCOVE LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-4602
Mailing Address - Country:US
Mailing Address - Phone:513-793-5150
Mailing Address - Fax:
Practice Address - Street 1:10426 BRIARCOVE LN
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-4602
Practice Address - Country:US
Practice Address - Phone:513-793-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3053152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0227016Medicaid
OHT46790Medicare UPIN
OHYO0420381Medicare ID - Type Unspecified