Basic Information
| Provider Information | |||||||||
| NPI: | 1295724748 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | YACOUB | ||||||||
| FirstName: | LILIANE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 TOTTEN POND RD | ||||||||
| Address2: | C/O MZI | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818909933 | ||||||||
| FaxNumber: | 7818909930 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 EAST ST | ||||||||
| Address2: | ATTN PATHOLOGY DEPT | ||||||||
| City: | METHUEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018444597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786870156 | ||||||||
| FaxNumber: | 9786915709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 02/25/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 81649 | MA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 767113 | 01 | MA | TUFTS | OTHER | 3159621 | 05 | MA | MEDICAID | 34738 | 01 | MA | HPHC | OTHER | J17222 | 01 | MA | BCBS | OTHER |