Provider Demographics
NPI:1962545194
Name:YOUNG, BEVERLY (OD)
Entity type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E GRANT LINE RD
Mailing Address - Street 2:#14
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-2763
Mailing Address - Country:US
Mailing Address - Phone:209-832-7839
Mailing Address - Fax:
Practice Address - Street 1:1138 NEWPARK MALL
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-5246
Practice Address - Country:US
Practice Address - Phone:510-790-1001
Practice Address - Fax:510-790-1704
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9185152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist