Provider Demographics
NPI:1427109099
Name:YOUNG, GARY PATRICK (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:PATRICK
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 1:12325 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:405-728-3454
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:405-728-3454
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2117152W00000X, 152WC0802X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA405782338OtherVISION SERVICE PLAN
OK100760340AMedicaid
OH117187OtherEYEMED VISION PLAN
OKU57128Medicare UPIN
OK$$$$$$$$$Medicare PIN