Basic Information
| Provider Information | |||||||||
| NPI: | 1417980483 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YACOUB | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2723 S 7TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478023558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122381730 | ||||||||
| FaxNumber: | 8122421565 | ||||||||
| Practice Location | |||||||||
| Address1: | 2723 S 7TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478023558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122328164 | ||||||||
| FaxNumber: | 8122346391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 06/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 01062336A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | P00404189 | 01 | IN | RAILROAD MEDICARE | OTHER | 200850550 | 05 | IN | MEDICAID | 000000501251 | 01 | IN | ANTHEM PIN | OTHER |