Provider Demographics
NPI:1972703676
Name:YUSUPOV, ROMAN (MD)
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:1131 N 35TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5403
Practice Address - Country:US
Practice Address - Phone:954-265-6319
Practice Address - Fax:954-276-0166
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 107047207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017236900Medicaid