Provider Demographics
NPI:1811093222
Name:ILIEVA, ANTOANETA (MD)
Entity type:Individual
Prefix:
First Name:ANTOANETA
Middle Name:
Last Name:ILIEVA
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 8792
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8792
Mailing Address - Country:US
Mailing Address - Phone:440-729-3644
Mailing Address - Fax:440-729-4239
Practice Address - Street 1:8185 E WASHINGTON ST STE 1
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44023-4574
Practice Address - Country:US
Practice Address - Phone:440-286-9588
Practice Address - Fax:440-286-2837
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081185207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2324069Medicaid
OH2324069Medicaid
H59615Medicare UPIN