Provider Demographics
NPI:1922341403
Name:YACOUB, SHIRLEY (MD)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:YACOUB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-226-4590
Mailing Address - Fax:386-226-4577
Practice Address - Street 1:2090 SAXON BLVD STE B
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-3251
Practice Address - Country:US
Practice Address - Phone:386-425-3300
Practice Address - Fax:386-425-3301
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME142341207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine