Provider Demographics
NPI:1306973110
Name:YACOUB, ROBERT MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:YACOUB
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1534 WEDGEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-2140
Mailing Address - Country:US
Mailing Address - Phone:714-328-5415
Mailing Address - Fax:
Practice Address - Street 1:2575 YORBA LINDA BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1615
Practice Address - Country:US
Practice Address - Phone:714-992-7842
Practice Address - Fax:714-992-7867
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13019 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist