Provider Demographics
NPI:1992793764
Name:YOUNG, JERRY STEVEN (OD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:STEVEN
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 1:201 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:CHILDRESS
Mailing Address - State:TX
Mailing Address - Zip Code:79201-4523
Mailing Address - Country:US
Mailing Address - Phone:940-937-4090
Mailing Address - Fax:940-937-7017
Practice Address - Street 1:201 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:CHILDRESS
Practice Address - State:TX
Practice Address - Zip Code:79201
Practice Address - Country:US
Practice Address - Phone:940-937-4090
Practice Address - Fax:940-937-7017
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4905TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U46038Medicare UPIN
81370EMedicare ID - Type Unspecified