Healthcare Provider Details

I. General information

NPI: 1558327866
Provider Name (Legal Business Name): MAGED LABIB YACOUB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 SPANOS CT #204
MODESTO CA
95355
US

IV. Provider business mailing address

1401 SPANOS CT #204
MODESTO CA
95355-2813
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-3875
  • Fax: 209-525-3876
Mailing address:
  • Phone: 209-525-3875
  • Fax: 209-525-3876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA54186
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: