Healthcare Provider Details

I. General information

NPI: 1972780351
Provider Name (Legal Business Name): G GARRY YACOUB O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: G GARRY YACOUB O.D.

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 WASHINGTON BLVD SUITE A-101
CONCORD CA
94521-4048
US

IV. Provider business mailing address

1460 WASHINGTON BLVD SUITE A-101
CONCORD CA
94521-4048
US

V. Phone/Fax

Practice location:
  • Phone: 925-672-4100
  • Fax: 925-672-4195
Mailing address:
  • Phone: 925-672-4100
  • Fax: 925-672-4195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number05621T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: