Provider Demographics
NPI:1750362521
Name:YUSUPOV, PINKHOZ (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:PINKHOZ
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11811 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7202
Mailing Address - Country:US
Mailing Address - Phone:718-793-2461
Mailing Address - Fax:718-785-2926
Practice Address - Street 1:11811 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7202
Practice Address - Country:US
Practice Address - Phone:718-793-2461
Practice Address - Fax:718-793-2455
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007169-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02245238Medicaid