Basic Information
| Provider Information | |||||||||
| NPI: | 1225316821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOUCHAK | ||||||||
| FirstName: | YASMIN | ||||||||
| MiddleName: | AGHA | ||||||||
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| Credential: | O.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6945 EL CAJON BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921151754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034344193 | ||||||||
| FaxNumber: | 6034376804 | ||||||||
| Practice Location | |||||||||
| Address1: | 6945 EL CAJON BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921151754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008982020 | ||||||||
| FaxNumber: | 8448973788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2011 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT14601TLG | CA | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 27OA00633500 | NJ | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 27OM00101000 | NJ | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 875 | NH | N | Eye and Vision Services Providers | Optometrist |
No ID Information.