Provider Demographics
NPI:1558929893
Name:DIMOVA, NEVIANA G (MD)
Entity Type:Individual
Prefix:
First Name:NEVIANA
Middle Name:G
Last Name:DIMOVA
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 950244
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0244
Mailing Address - Country:US
Mailing Address - Phone:502-953-4700
Mailing Address - Fax:502-772-8189
Practice Address - Street 1:4100 TAYLOR BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-2342
Practice Address - Country:US
Practice Address - Phone:502-953-4700
Practice Address - Fax:502-772-8189
Is Sole Proprietor?:No
Enumeration Date:2019-06-02
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21469208D00000X
FLACN1440208D00000X
PR14862390200000X
KY58646208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program