Provider Demographics
NPI:1720123094
Name:YAQUB, MUHAMMAD (MD)
Entity Type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:
Last Name:YAQUB
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 1:13677 FOOTHILL BLVD
Mailing Address - Street 2:SUITE Q
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-0505
Mailing Address - Country:US
Mailing Address - Phone:909-899-7800
Mailing Address - Fax:909-899-3163
Practice Address - Street 1:13677 FOOTHILL BLVD
Practice Address - Street 2:SUITE Q
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-0505
Practice Address - Country:US
Practice Address - Phone:909-899-7800
Practice Address - Fax:909-899-3163
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A45127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A451271Medicaid
CA00A451271Medicaid
CAZZZ35033ZMedicare ID - Type Unspecified