Provider Demographics
NPI:1770198871
Name:SONOMA MEDICAL P.C.
Entity Type:Organization
Organization Name:SONOMA MEDICAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ARKADY
Authorized Official - Middle Name:
Authorized Official - Last Name:YUSUPOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-624-3341
Mailing Address - Street 1:1361 BROADWAY APT B32
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1342
Mailing Address - Country:US
Mailing Address - Phone:347-624-3341
Mailing Address - Fax:347-789-7415
Practice Address - Street 1:21 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-3215
Practice Address - Country:US
Practice Address - Phone:347-624-3341
Practice Address - Fax:347-789-7415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty