Basic Information
| Provider Information | |||||||||
| NPI: | 1609857184 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 SW WANAMAKER RD | ||||||||
| Address2: | SUITE 192 | ||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666144293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852720707 | ||||||||
| FaxNumber: | 7852711512 | ||||||||
| Practice Location | |||||||||
| Address1: | 3012 ANDERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665032809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855371118 | ||||||||
| FaxNumber: | 7855378005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 06/25/2010 | ||||||||
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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 | KS1023-3 | KS | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 100090900A | 05 | KS | MEDICAID | 410020620 | 01 | KS | RAILROAD MEDICARE | OTHER | 005286 | 01 | BCBS | OTHER |