Healthcare Provider Details

I. General information

NPI: 1003847237
Provider Name (Legal Business Name): IRINA KOSTOVA DIMITROVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N LAKE DR
MILWAUKEE WI
53211-4528
US

IV. Provider business mailing address

400 W RIVER WOODS PKWY
GLENDALE WI
53212-1060
US

V. Phone/Fax

Practice location:
  • Phone: 414-585-1949
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01088502A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301080622
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number44128
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD60306703
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberDR.0044128
License Number StateCO
# 6
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMD209404
License Number StateOR
# 7
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number4301080622
License Number StateMI
# 8
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMD479477
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: