Provider Demographics
NPI:1134256761
Name:21ST AVENUE MEDICAL PLAZA PC
Entity type:Organization
Organization Name:21ST AVENUE MEDICAL PLAZA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SAMIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:OVSHAEV
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-266-9779
Mailing Address - Street 1:2101 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4401
Mailing Address - Country:US
Mailing Address - Phone:718-266-9779
Mailing Address - Fax:718-645-6600
Practice Address - Street 1:2101 E 16TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4401
Practice Address - Country:US
Practice Address - Phone:718-266-9779
Practice Address - Fax:718-645-6600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208817208100000X
NY219865208VP0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1681P2OtherEMPIRE BCBS
NY219865OtherLICENSE
NY02263427Medicaid
NYBO7117319OtherDEA
NYH53380Medicare UPIN