Provider Demographics
NPI:1003847237
Name:DIMITROVA, IRINA KOSTOVA (MD)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:KOSTOVA
Last Name:DIMITROVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:717-531-6585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01088502A207V00000X
MI4301080622207V00000X, 207VX0201X
WAMD60306703207V00000X
CO44128207V00000X
CODR.0044128207VX0201X
ORMD209404207VX0201X
PAMD479477207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0300248OtherLABOR AND INDUSTRY
AKMD00521OtherALASKA DSHS
WA1003847237Medicaid
CO06728766Medicaid
WA0300248OtherLABOR AND INDUSTRY
WA1003847237Medicaid