Provider Demographics
NPI:1184619009
Name:YOUNG, KENNETH A (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
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 1:205 WARD CIR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7552
Mailing Address - Country:US
Mailing Address - Phone:615-373-0080
Mailing Address - Fax:615-373-2848
Practice Address - Street 1:205 WARD CIR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7552
Practice Address - Country:US
Practice Address - Phone:615-373-0080
Practice Address - Fax:615-373-2848
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1488152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3599062Medicaid
TN3599062Medicaid