Provider Demographics
NPI:1548350853
Name:IVANOVA NESCH, RADOSVETA GEORGIEVA ODISEEVA (MD)
Entity type:Individual
Prefix:DR
First Name:RADOSVETA
Middle Name:GEORGIEVA ODISEEVA
Last Name:IVANOVA NESCH
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 1:1105 W 163RD AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-9233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 W 86TH AVE STE B
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6192
Practice Address - Country:US
Practice Address - Phone:219-756-6605
Practice Address - Fax:219-756-6615
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049149207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ING84509Medicare UPIN
IN184800Medicare ID - Type Unspecified