Healthcare Provider Details

I. General information

NPI: 1477282960
Provider Name (Legal Business Name): DANIEL YUSUPOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33501 1ST WAY S
FEDERAL WAY WA
98003-6208
US

IV. Provider business mailing address

PO BOX 741515
LOS ANGELES CA
90074-1515
US

V. Phone/Fax

Practice location:
  • Phone: 253-838-2400
  • Fax:
Mailing address:
  • Phone: 253-838-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD70116362
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: