Provider Demographics
NPI:1013422401
Name:YOUNG EYE CLINIC LLC
Entity Type:Organization
Organization Name:YOUNG EYE CLINIC LLC
Other - Org Name:YOUNG EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-728-3393
Mailing Address - Street 1:12325 N ROCKWELL AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-2702
Mailing Address - Country:US
Mailing Address - Phone:405-728-3393
Mailing Address - Fax:
Practice Address - Street 1:12325 N ROCKWELL AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-2702
Practice Address - Country:US
Practice Address - Phone:405-728-3393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2117152W00000X, 152WC0802X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
918288OtherEYEMED
OK100760340AMedicaid
CA4057283393OtherVISION SERVICE PLAN