Healthcare Provider Details

I. General information

NPI: 1326077280
Provider Name (Legal Business Name): TAHIR YAQUB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 01/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 3RD ST
ATWATER CA
95301-3608
US

IV. Provider business mailing address

1775 3RD ST
ATWATER CA
95301-3608
US

V. Phone/Fax

Practice location:
  • Phone: 209-358-5611
  • Fax: 209-358-0219
Mailing address:
  • Phone: 209-358-5611
  • Fax: 209-358-0219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA96088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: