1548317027 NPI number — PATRICIA YOUNGQUIST OD, LLC

Table of content: (NPI 1548317027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548317027 NPI number — PATRICIA YOUNGQUIST OD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATRICIA YOUNGQUIST OD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548317027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
186 LANSDOWNE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESHIRE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06410-1584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-272-3342
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 COMMERCIAL PKWY
Provider Second Line Business Practice Location Address:
VISION CENTER
Provider Business Practice Location Address City Name:
BRANFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06405-2537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-483-1901
Provider Business Practice Location Address Fax Number:
203-488-3560
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNGQUIST
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
203-272-3342

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2200 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11466814 . This is a "CAQH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 687443 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 411-8619 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 090002200CT15 . This is a "BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 118229 . This is a "EYEMED" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V6044 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 919749 . This is a "BLOCK" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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