Provider Demographics
NPI:1144413741
Name:YUSUPOV, DMITRIY
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2448
Mailing Address - Country:US
Mailing Address - Phone:718-932-1000
Mailing Address - Fax:
Practice Address - Street 1:2510 30TH AVE
Practice Address - Street 2:MOUNT SINAI HOSPITAL OF QUEENS
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11102-2448
Practice Address - Country:US
Practice Address - Phone:718-932-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012020363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical