Provider Demographics
NPI:1396144168
Name:YACOUB, JOHN WAGEEH MAHROUS
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WAGEEH MAHROUS
Last Name:YACOUB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 SHORE PKWY APT 4J
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-6142
Mailing Address - Country:US
Mailing Address - Phone:440-654-7974
Mailing Address - Fax:
Practice Address - Street 1:295 E CAROLINE ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3700
Practice Address - Country:US
Practice Address - Phone:909-723-1161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292523225100000X
NY035016225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist