Healthcare Provider Details

I. General information

NPI: 1588915730
Provider Name (Legal Business Name): JACK YACOO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 FROST ST
SAN DIEGO CA
92123-2701
US

IV. Provider business mailing address

8765 AERO DR STE 130
SAN DIEGO CA
92123-1767
US

V. Phone/Fax

Practice location:
  • Phone: 858-939-3400
  • Fax:
Mailing address:
  • Phone: 858-541-0181
  • Fax: 858-430-0919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA125539
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: