Provider Demographics
NPI:1477527364
Name:YAACOUBAGHA, WADDAH (MD)
Entity Type:Individual
Prefix:
First Name:WADDAH
Middle Name:
Last Name:YAACOUBAGHA
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 1:1055 DOVE RUN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502
Mailing Address - Country:US
Mailing Address - Phone:859-269-4668
Mailing Address - Fax:859-266-5577
Practice Address - Street 1:1055 DOVE RUN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502
Practice Address - Country:US
Practice Address - Phone:859-269-4668
Practice Address - Fax:859-266-5577
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36958207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H21972Medicare UPIN