Provider Demographics
NPI:1265818777
Name:YACOUB, ATHEER (RD)
Entity Type:Individual
Prefix:
First Name:ATHEER
Middle Name:
Last Name:YACOUB
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 LEXINGTON AVE
Mailing Address - Street 2:22
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1575 LEXINGTON AVE
Practice Address - Street 2:22
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6214
Practice Address - Country:US
Practice Address - Phone:205-586-4648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY991832133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered