Provider Demographics
NPI:1225741606
Name:YUSUPOVA, YELENA
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:YUSUPOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 CENTRAL AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-1930
Mailing Address - Country:US
Mailing Address - Phone:516-303-2410
Mailing Address - Fax:
Practice Address - Street 1:415 CENTRAL AVE UNIT A
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-1930
Practice Address - Country:US
Practice Address - Phone:516-303-2410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010097156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician