Provider Demographics
NPI:1053765388
Name:YUSUPOV, ARTEM (AUD)
Entity type:Individual
Prefix:
First Name:ARTEM
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10825 72ND AVE
Mailing Address - Street 2:STE 1A
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7831
Mailing Address - Country:US
Mailing Address - Phone:347-561-9535
Mailing Address - Fax:347-561-9513
Practice Address - Street 1:10825 72ND AVE
Practice Address - Street 2:STE 1A
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7831
Practice Address - Country:US
Practice Address - Phone:718-480-8556
Practice Address - Fax:347-561-9513
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-23
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00255881231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1134597701OtherGROUP NPI
NYA100146813OtherSOLO MEDICARE PTAN
NY002588-1OtherNYS AUDIOLOGY LICENSE
NYA400146814OtherGROUP MEDICARE PTAN
NY04407801Medicaid