Provider Demographics
NPI:1235164476
Name:YAKLIC, JEROME L (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:L
Last Name:YAKLIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-5303
Mailing Address - Country:US
Mailing Address - Phone:409-772-1957
Mailing Address - Fax:937-245-7999
Practice Address - Street 1:1005 HARBORSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-2722
Practice Address - Country:US
Practice Address - Phone:409-772-9507
Practice Address - Fax:409-747-5570
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059625207VF0040X, 207V00000X
TXS6330207VF0040X, 207V00000X
OH35-075267207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1603210171OtherBCBSM
MI4645433Medicaid
MI4645433Medicaid
MIN97260002Medicare ID - Type Unspecified