Provider Demographics
NPI:1245576974
Name:YAQUB, IRUM (MD)
Entity Type:Individual
Prefix:
First Name:IRUM
Middle Name:
Last Name:YAQUB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 HIGHLAND PARK BLVD
Mailing Address - Street 2:STE D
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1639
Mailing Address - Country:US
Mailing Address - Phone:314-977-4850
Mailing Address - Fax:314-977-4880
Practice Address - Street 1:1438 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1027
Practice Address - Country:US
Practice Address - Phone:314-977-4850
Practice Address - Fax:314-977-4880
Is Sole Proprietor?:No
Enumeration Date:2012-12-28
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1309842084P0800X
MO2012042476390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program