Provider Demographics
NPI:1205881109
Name:ROGER YOUNG, PC
Entity type:Organization
Organization Name:ROGER YOUNG, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:609-886-7156
Mailing Address - Street 1:2004 BAYSHORE RD
Mailing Address - Street 2:
Mailing Address - City:VILLAS
Mailing Address - State:NJ
Mailing Address - Zip Code:08251-1815
Mailing Address - Country:US
Mailing Address - Phone:609-886-1578
Mailing Address - Fax:609-886-3520
Practice Address - Street 1:2004 BAYSHORE RD
Practice Address - Street 2:
Practice Address - City:VILLAS
Practice Address - State:NJ
Practice Address - Zip Code:08251-1815
Practice Address - Country:US
Practice Address - Phone:609-886-1578
Practice Address - Fax:609-886-3520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00383700332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1865609Medicaid
NJ0130160001Medicare NSC