Provider Demographics
NPI:1205959673
Name:DR. G GARRY YACOUB OD
Entity type:Organization
Organization Name:DR. G GARRY YACOUB OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:G
Authorized Official - Middle Name:GARRY
Authorized Official - Last Name:YACOUB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:925-672-4100
Mailing Address - Street 1:1460 WASHINGTON BLVD
Mailing Address - Street 2:A101
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:
Practice Address - Street 1:1460 WASHINGTON BLVD
Practice Address - Street 2:A101
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05621305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0056210Medicare PIN