Provider Demographics
NPI:1851394688
Name:YOUNG, DALE A (OD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:A
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 1:20231 W VALLEY BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:TEHACHAPI
Mailing Address - State:CA
Mailing Address - Zip Code:93561-6748
Mailing Address - Country:US
Mailing Address - Phone:661-822-1212
Mailing Address - Fax:
Practice Address - Street 1:20231 W VALLEY BLVD STE G
Practice Address - Street 2:
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-6748
Practice Address - Country:US
Practice Address - Phone:661-822-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5799T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0057990Medicaid
CAU51363Medicare UPIN
CASD0057990Medicaid