Provider Demographics
NPI:1891934923
Name:YUSUPOV, ELEANOR (DO)
Entity Type:Individual
Prefix:DR
First Name:ELEANOR
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8000
Mailing Address - Street 2:NORTHERN BOULEVARD, ACADEMIC HEALTH CARE CENTER
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-8000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NORTHERN BOULEVARD ACADEMIC HEALTH CARE CENTER
Practice Address - Street 2:NYIT COLLEGE OF OSTEOPATHIC MEDICINE
Practice Address - City:OLD WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11568-8000
Practice Address - Country:US
Practice Address - Phone:516-686-3751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247945207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY247945OtherNYS LICENSE