Basic Information
| Provider Information | |||||||||
| NPI: | 1467861864 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 S WEBER RD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307710600 | ||||||||
| FaxNumber: | 6307599692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2014 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA2417 | MD | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 046.010895 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.