Provider Demographics
NPI:1417980483
Name:YACOUB, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:YACOUB
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 1:2723 S 7TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3558
Mailing Address - Country:US
Mailing Address - Phone:812-238-1730
Mailing Address - Fax:812-242-1565
Practice Address - Street 1:2723 S 7TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3558
Practice Address - Country:US
Practice Address - Phone:812-232-8164
Practice Address - Fax:812-234-6391
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062336A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00404189OtherRAILROAD MEDICARE
IN200850550Medicaid
IN000000501251OtherANTHEM PIN
IN147180XXMedicare PIN
IN941090A66Medicare PIN
ING38022Medicare UPIN