Provider Demographics
NPI:1083959217
Name:YAQOUB, ABDELHAMEED
Entity Type:Individual
Prefix:
First Name:ABDELHAMEED
Middle Name:
Last Name:YAQOUB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11225 N 28TH DR STE C207
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-5600
Mailing Address - Country:US
Mailing Address - Phone:602-367-7916
Mailing Address - Fax:602-367-7916
Practice Address - Street 1:11225 N 28TH DR STE C207
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-5600
Practice Address - Country:US
Practice Address - Phone:602-367-7916
Practice Address - Fax:602-997-1552
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ560174172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver