Provider Demographics
NPI:1356634554
Name:ADVANCED OB/GYN, PC
Entity Type:Organization
Organization Name:ADVANCED OB/GYN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMILA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGAYAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-336-1909
Mailing Address - Street 1:1725 E 12TH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1028
Mailing Address - Country:US
Mailing Address - Phone:718-336-1909
Mailing Address - Fax:718-336-1929
Practice Address - Street 1:1725 E 12TH ST
Practice Address - Street 2:#301
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1028
Practice Address - Country:US
Practice Address - Phone:718-336-1909
Practice Address - Fax:718-336-1929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-20
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226831207V00000X
NY238834207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1457364804OtherNPI