Provider Demographics
NPI:1578662631
Name:DIMOV, IVAILO DICHEV (MD)
Entity Type:Individual
Prefix:
First Name:IVAILO
Middle Name:DICHEV
Last Name:DIMOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BLACKHAWK RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-5227
Mailing Address - Country:US
Mailing Address - Phone:847-208-0532
Mailing Address - Fax:
Practice Address - Street 1:77 BLACKHAWK RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-5227
Practice Address - Country:US
Practice Address - Phone:847-208-0532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101550207L00000X
CAA76262207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAQ381YMedicare PIN