Healthcare Provider Details

I. General information

NPI: 1841273638
Provider Name (Legal Business Name): ROSEN K DIMITROV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 952-967-7977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number45659-020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number73085
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number01059563A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: