Healthcare Provider Details

I. General information

NPI: 1134256761
Provider Name (Legal Business Name): 21ST AVENUE MEDICAL PLAZA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 E 16TH ST
BROOKLYN NY
11229-4401
US

IV. Provider business mailing address

2101 E 16TH ST
BROOKLYN NY
11229-4401
US

V. Phone/Fax

Practice location:
  • Phone: 718-266-9779
  • Fax: 718-645-6600
Mailing address:
  • Phone: 718-266-9779
  • Fax: 718-645-6600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number219865
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number208817
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number219865
License Number StateNY

VIII. Authorized Official

Name: SAMIRA OVSHAEV
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 718-266-9779