Provider Demographics
NPI:1154770030
Name:YUSUPOV, SANDZHAR
Entity type:Individual
Prefix:
First Name:SANDZHAR
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 WASHINGTON ST
Mailing Address - Street 2:STE #474
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-4006
Mailing Address - Country:US
Mailing Address - Phone:781-821-3411
Mailing Address - Fax:781-634-0508
Practice Address - Street 1:95 WASHINGTON ST
Practice Address - Street 2:STE #474
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-4006
Practice Address - Country:US
Practice Address - Phone:781-821-3411
Practice Address - Fax:781-634-0508
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications