Provider Demographics
NPI:1003847237
Name:DIMITROVA, IRINA KOSTOVA (MD)
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:KOSTOVA
Last Name:DIMITROVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W RIVER WOODS PKWY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-585-1949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01088502A207V00000X
MI4301080622207V00000X, 207VX0201X
CO44128207V00000X
WAMD60306703207V00000X
CODR.0044128207VX0201X
ORMD209404207VX0201X
PAMD479477207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0300248OtherLABOR AND INDUSTRY
WA1003847237Medicaid
CO06728766Medicaid
AKMD00521OtherALASKA DSHS
WA0300248OtherLABOR AND INDUSTRY
WA1003847237Medicaid