Healthcare Provider Details

I. General information

NPI: 1972847671
Provider Name (Legal Business Name): MICHAEL YACOUB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610
US

IV. Provider business mailing address

311 N CLYDE MORRIS BLVD STE 100
DAYTONA BEACH FL
32114-2756
US

V. Phone/Fax

Practice location:
  • Phone: 325-273-5484
  • Fax:
Mailing address:
  • Phone: 386-226-2662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301093311
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number26404
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number63402
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME136710
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: