Provider Demographics
NPI:1437502911
Name:YUSUPOV, ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 102ND ST
Mailing Address - Street 2:APT E7
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3130 GRAND CONCOURSE
Practice Address - Street 2:STE 1J
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-1213
Practice Address - Country:US
Practice Address - Phone:718-741-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist