Provider Demographics
NPI:1417346321
Name:SOURIAL, MARYANNE YACOUB (DO)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:YACOUB
Last Name:SOURIAL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 MEADOW LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-2504
Mailing Address - Country:US
Mailing Address - Phone:201-888-2698
Mailing Address - Fax:
Practice Address - Street 1:3411 WAYNE AVE APT 5H
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2539
Practice Address - Country:US
Practice Address - Phone:718-920-5442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288330207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology