Provider Demographics
NPI:1396744124
Name:YOUNG, ROGER ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALLEN
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 1:2004 BAYSHORE RD
Mailing Address - Street 2:
Mailing Address - City:VILLAS
Mailing Address - State:NJ
Mailing Address - Zip Code:08251-1815
Mailing Address - Country:US
Mailing Address - Phone:609-886-1578
Mailing Address - Fax:609-886-3520
Practice Address - Street 1:2004 BAYSHORE RD
Practice Address - Street 2:
Practice Address - City:VILLAS
Practice Address - State:NJ
Practice Address - Zip Code:08251-1815
Practice Address - Country:US
Practice Address - Phone:609-886-1578
Practice Address - Fax:609-886-3520
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00383700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0130160001Medicare NSC