Provider Demographics
NPI:1285625384
Name:YACOUBIAN, STEPHAN VAHE (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:VAHE
Last Name:YACOUBIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2625 W ALAMEDA AVE
Mailing Address - Street 2:STE 116
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4806
Mailing Address - Country:US
Mailing Address - Phone:818-841-3936
Mailing Address - Fax:818-841-5974
Practice Address - Street 1:2625 W ALAMEDA AVE
Practice Address - Street 2:STE 116
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4806
Practice Address - Country:US
Practice Address - Phone:818-841-3936
Practice Address - Fax:818-841-5974
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77306207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A773060Medicaid
CAWA77306AMedicare PIN
CACB245257Medicare PIN
H59503Medicare UPIN
CA00A773060Medicaid