Provider Demographics
NPI:1225316821
Name:KOUCHAK, YASMIN AGHA (OD)
Entity Type:Individual
Prefix:
First Name:YASMIN
Middle Name:AGHA
Last Name:KOUCHAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6945 EL CAJON BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-1754
Mailing Address - Country:US
Mailing Address - Phone:603-434-4193
Mailing Address - Fax:603-437-6804
Practice Address - Street 1:6945 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-1754
Practice Address - Country:US
Practice Address - Phone:800-898-2020
Practice Address - Fax:844-897-3788
Is Sole Proprietor?:No
Enumeration Date:2011-07-30
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT14601TLG152W00000X
NJ27OA00633500152W00000X
NJ27OM00101000152W00000X
NH875152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist