Provider Demographics
NPI:1962471938
Name:DIMITROV, ADAM (MD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:DIMITROV
Suffix:
Gender:M
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:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:13000 SAWGRASS VILLAGE CIR STE 46
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-5023
Practice Address - Country:US
Practice Address - Phone:904-202-6348
Practice Address - Fax:904-376-3019
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102216207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0008301-00Medicaid
FLP00710723OtherRR MEDICARE
FL0008301-00Medicaid
I40917Medicare UPIN
FLP00710723OtherRR MEDICARE
MD004367200Medicaid
MD75859901OtherBLUE SHIELD
I40917Medicare UPIN