Provider Demographics
NPI:1972780351
Name:YACOUB, G GARRY (OD)
Entity Type:Individual
Prefix:
First Name:G GARRY
Middle Name:
Last Name:YACOUB
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:G GARRY
Other - Middle Name:
Other - Last Name:YACOUB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1460 WASHINGTON BLVD
Mailing Address - Street 2:SUITE A-101
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-4048
Mailing Address - Country:US
Mailing Address - Phone:925-672-4100
Mailing Address - Fax:925-672-4195
Practice Address - Street 1:1460 WASHINGTON BLVD
Practice Address - Street 2:SUITE A-101
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94521-4048
Practice Address - Country:US
Practice Address - Phone:925-672-4100
Practice Address - Fax:925-672-4195
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05621T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0056210Medicare PIN