Provider Demographics
NPI:1548827710
Name:IVANOV, NEDYALKO NEDYALKOV (DO)
Entity type:Individual
Prefix:DR
First Name:NEDYALKO
Middle Name:NEDYALKOV
Last Name:IVANOV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 HOSPITAL BLVD STE 280
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4918
Mailing Address - Country:US
Mailing Address - Phone:770-754-0787
Mailing Address - Fax:
Practice Address - Street 1:2500 HOSPITAL BLVD STE 280
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4918
Practice Address - Country:US
Practice Address - Phone:770-754-0787
Practice Address - Fax:770-755-5890
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101026012207N00000X
GA15530207N00000X
FL20723207N00000X
GA98733207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology