Healthcare Provider Details

I. General information

NPI: 1306973110
Provider Name (Legal Business Name): ROBERT MICHAEL YACOUB O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 YORBA LINDA BLVD
FULLERTON CA
92831-1615
US

IV. Provider business mailing address

1534 WEDGEWOOD WAY
UPLAND CA
91786-2140
US

V. Phone/Fax

Practice location:
  • Phone: 714-992-7842
  • Fax: 714-992-7867
Mailing address:
  • Phone: 714-328-5415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13019 TPA
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: