Basic Information
| Provider Information | |||||||||
| NPI: | 1770746695 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIMITROV | ||||||||
| FirstName: | DIMITRE | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2215 FULLER RD DEPT OF | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481052303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347697100 | ||||||||
| FaxNumber: | 7348453235 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 FULLER RD DEPT OF | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481052303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347697100 | ||||||||
| FaxNumber: | 7348453235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2008 | ||||||||
| LastUpdateDate: | 07/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0015X | 53629 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychosomatic Medicine | 2084P0015X | 446 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychosomatic Medicine | 284300000X | N | Hospitals | Special Hospital |
ID Information
| ID | Type | State | Issuer | Description | 4301081427 | 01 | MI | PHYSICAIN LICENSE | OTHER |