Basic Information
| Provider Information | |||||||||
| NPI: | 1003847237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIMITROVA | ||||||||
| FirstName: | IRINA | ||||||||
| MiddleName: | KOSTOVA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 8111 S EMERSON AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462378601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175282555 | ||||||||
| FaxNumber: | 3175282566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4301080622 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | MD60306703 | WA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 44128 | CO | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VX0201X | MD209404 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207VX0201X | 4301080622 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207VX0201X | DR.0044128 | CO | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207V00000X | 01088502A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0300248 | 01 | WA | LABOR AND INDUSTRY | OTHER | 06728766 | 05 | CO | MEDICAID | MD00521 | 01 | AK | ALASKA DSHS | OTHER | 1003847237 | 05 | WA | MEDICAID |