Provider Demographics
NPI:1851774038
Name:YUSUPOV, SUSAN
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:YAGUDAYEV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1561 E 13TH ST
Mailing Address - Street 2:APT F9
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-7159
Mailing Address - Country:US
Mailing Address - Phone:646-670-3490
Mailing Address - Fax:
Practice Address - Street 1:1561 E 13TH ST
Practice Address - Street 2:APT F9
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-7159
Practice Address - Country:US
Practice Address - Phone:646-670-3490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1254274174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist