Basic Information
| Provider Information | |||||||||
| NPI: | 1154485670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG-DORSER | ||||||||
| FirstName: | KAYLIN | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YOUNG | ||||||||
| OtherFirstName: | KAYLIN | ||||||||
| OtherMiddleName: | K. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 94-1480 MOANIANI ST | ||||||||
| Address2: | |||||||||
| City: | WAIPAHU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967974632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084323100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 94-1480 MOANIANI ST | ||||||||
| Address2: | |||||||||
| City: | WAIPAHU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967974632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084323100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD-632 | HI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0000255620 | 01 | HI | HMSA BILLING NUMBER | OTHER | 575954-05 | 05 | HI | MEDICAID |