Provider Demographics
NPI:1396821732
Name:MASSUDA, YACOUB (MD)
Entity Type:Individual
Prefix:DR
First Name:YACOUB
Middle Name:
Last Name:MASSUDA
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 1:105 WILDROSE CT
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-6044
Mailing Address - Country:US
Mailing Address - Phone:219-462-1321
Mailing Address - Fax:
Practice Address - Street 1:814 LAPORTE AVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5860
Practice Address - Country:US
Practice Address - Phone:219-465-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024734A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000208898OtherBC BS IN PROVIDER #
IN000000208898OtherBC BS IN PROVIDER #
IN653750AMedicare ID - Type Unspecified