Provider Demographics
NPI:1740203777
Name:YACOUBIAN, VAHE STEPHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:VAHE
Middle Name:STEPHAN
Last Name:YACOUBIAN
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 1:610 N CENTRAL AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1403
Mailing Address - Country:US
Mailing Address - Phone:818-500-0779
Mailing Address - Fax:808-500-1579
Practice Address - Street 1:610 N CENTRAL AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1403
Practice Address - Country:US
Practice Address - Phone:818-500-0779
Practice Address - Fax:808-500-1579
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39812174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C398121Medicaid
CAD64663Medicare UPIN
CAC39812Medicare ID - Type Unspecified