Healthcare Provider Details

I. General information

NPI: 1639518178
Provider Name (Legal Business Name): ALBERT YUSUPOV D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE DEPARTMENT OF ANESTHESIOLOGY
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

30 PROSPECT AVE DEPARTMENT OF ANESTHESIOLOGY
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2419
  • Fax: 551-996-3962
Mailing address:
  • Phone: 551-996-2419
  • Fax: 551-996-3962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MB09828400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: