Provider Demographics
NPI:1982762845
Name:ILIEV, DESSISLAVA DIMOTROVA (MD)
Entity Type:Individual
Prefix:MRS
First Name:DESSISLAVA
Middle Name:DIMOTROVA
Last Name:ILIEV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DESSISLAVA
Other - Middle Name:D
Other - Last Name:BUCHKOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY, SUITE S108-A
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-984-5936
Mailing Address - Fax:601-984-5939
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY, SUITE S108-A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5936
Practice Address - Fax:601-984-5939
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24023207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03620888Medicaid
NY5RR431Medicare PIN
I23029Medicare UPIN
MS442088YJ5DMedicare PIN