=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407773526
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NYC MODERN GYNECOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2026
-----------------------------------------------------
Last Update Date | 06/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1624 DR MARTIN L KING JR BLVD
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10453-6948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-294-3725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 839 DUNCAN DR
-----------------------------------------------------
City | WESTBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11590-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DESRENE BROWN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 419-721-4026
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------