Provider Demographics
NPI:1265537666
Name:YOUNG, MICHELINE D (OD)
Entity type:Individual
Prefix:MRS
First Name:MICHELINE
Middle Name:D
Last Name:YOUNG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:MICHELINE
Other - Middle Name:D
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:302 E HIGHWAY 190
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-2939
Mailing Address - Country:US
Mailing Address - Phone:254-547-2683
Mailing Address - Fax:254-547-4099
Practice Address - Street 1:304 E HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-2939
Practice Address - Country:US
Practice Address - Phone:254-547-2020
Practice Address - Fax:254-542-6060
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3854TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164318101Medicaid
TX164318101Medicaid
TX83779EMedicare PIN
TX8F7121Medicare PIN