Provider Demographics
NPI:1548465552
Name:DIMITROVA, DESSISLAVA I (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:DESSISLAVA
Middle Name:I
Last Name:DIMITROVA
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 WHITEHORSE MERCERVILLE RD STE 219
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-3835
Mailing Address - Country:US
Mailing Address - Phone:609-584-5150
Mailing Address - Fax:609-815-5150
Practice Address - Street 1:1401 WHITEHORSE MERCERVILLE ROAD
Practice Address - Street 2:SUITE 219
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-3834
Practice Address - Country:US
Practice Address - Phone:609-587-5150
Practice Address - Fax:609-584-5144
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08265100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0137294Medicaid
NJ114593Medicare PIN