Provider Demographics
NPI:1104818343
Name:DIMOVA, ANETA K (MD)
Entity type:Individual
Prefix:DR
First Name:ANETA
Middle Name:K
Last Name:DIMOVA
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 1:111 MARY'S AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-5853
Mailing Address - Country:US
Mailing Address - Phone:845-339-3663
Mailing Address - Fax:845-339-3629
Practice Address - Street 1:111 MARY'S AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5853
Practice Address - Country:US
Practice Address - Phone:845-339-3663
Practice Address - Fax:845-339-3629
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204325207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01673225Medicaid
NYRB1746Medicare PIN
NY71506NW001Medicare PIN
NYG34655Medicare UPIN