Provider Demographics
NPI:1982991485
Name:YUSUPOV, STEVE (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:STEVE
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:DR
Other - First Name:STEVE
Other - Middle Name:
Other - Last Name:YUSUPOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MD
Mailing Address - Street 1:256-C MASON AVENUE 3RD FLOOR
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1851
Mailing Address - Country:US
Mailing Address - Phone:718-226-1251
Mailing Address - Fax:
Practice Address - Street 1:55 BRYANT AVE
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1139
Practice Address - Country:US
Practice Address - Phone:516-749-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057086204E00000X
NY285541207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
FY3540451OtherDEA