Provider Demographics
NPI:1639409840
Name:YUSUPOV, ELDAD (RN)
Entity Type:Individual
Prefix:MR
First Name:ELDAD
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2519
Mailing Address - Country:US
Mailing Address - Phone:516-887-1200
Mailing Address - Fax:
Practice Address - Street 1:50 BROADWAY
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-2519
Practice Address - Country:US
Practice Address - Phone:516-887-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-11
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY588677163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY588633OtherREGISTERED NURSE LICENSE