Healthcare Provider Details

I. General information

NPI: 1770546533
Provider Name (Legal Business Name): WAEL YACOUB M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 PERSHING BLVD
WHITEHALL PA
18052-6452
US

IV. Provider business mailing address

450 PERSHING BLVD
WHITEHALL PA
18052
US

V. Phone/Fax

Practice location:
  • Phone: 610-434-6678
  • Fax: 610-434-6671
Mailing address:
  • Phone: 610-434-6678
  • Fax: 610-434-6671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD418291
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: