Provider Demographics
NPI:1629367198
Name:RADEVA, IVANA ANGELIEVA (MD)
Entity Type:Individual
Prefix:
First Name:IVANA
Middle Name:ANGELIEVA
Last Name:RADEVA
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 1:220 BAY ST APT 213
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18321 CLARK ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3501
Practice Address - Country:US
Practice Address - Phone:818-708-5285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA123727207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology