Provider Demographics
NPI:1134548464
Name:DIMITROV, MYRA DIMITROV (MD)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:DIMITROV
Last Name:DIMITROV
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 1:2323 S TRUNK RD APT 6
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-5940
Mailing Address - Country:US
Mailing Address - Phone:907-746-6644
Mailing Address - Fax:
Practice Address - Street 1:2323 S TRUNK RD APT 6
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645
Practice Address - Country:US
Practice Address - Phone:907-746-6644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK125163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine