Healthcare Provider Details

I. General information

NPI: 1972652972
Provider Name (Legal Business Name): RADOSVETA STOYANOV MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-3909
  • Fax: 616-336-8830
Mailing address:
  • Phone: 616-455-5000
  • Fax: 616-455-5460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number84103
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number84103
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: