Healthcare Provider Details

I. General information

NPI: 1164616157
Provider Name (Legal Business Name): MOHAMMAD M. YAQUB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: N/A N/A N/A MD

II. Dates (important events)

Enumeration Date: 09/01/2007
Last Update Date: 09/26/2023
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 JOHN F KENNEDY DR
ATLANTIS FL
33462-1119
US

IV. Provider business mailing address

101 JOHN F KENNEDY DR
ATLANTIS FL
33462-1119
US

V. Phone/Fax

Practice location:
  • Phone: 561-612-8080
  • Fax: 561-612-8084
Mailing address:
  • Phone: 561-612-8080
  • Fax: 561-612-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME99808
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: