Provider Demographics
NPI:1366728396
Name:YUSUPOV, ROBERT
Entity type:Individual
Prefix:MR
First Name:ROBERT
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 1:32-41A STEINWAY STREET
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103
Mailing Address - Country:US
Mailing Address - Phone:347-808-9155
Mailing Address - Fax:347-808-9156
Practice Address - Street 1:32-41 STEINWAY STREET
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103
Practice Address - Country:US
Practice Address - Phone:347-808-9155
Practice Address - Fax:347-808-9156
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007608156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician