1457501827 NPI number — DR. IVAN JOSE BUSTILLO CHAMS MD

Table of content: DR. IVAN JOSE BUSTILLO CHAMS MD (NPI 1457501827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457501827 NPI number — DR. IVAN JOSE BUSTILLO CHAMS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSTILLO CHAMS
Provider First Name:
IVAN
Provider Middle Name:
JOSE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457501827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13780
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-780-1891
Provider Business Mailing Address Fax Number:
203-789-5184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ALTRU CANCER CENTER
Provider Second Line Business Practice Location Address:
960 S. COLUMBIA ROAD
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-780-5400
Provider Business Practice Location Address Fax Number:
203-789-5184
Provider Enumeration Date:
09/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  PT12924 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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