Provider Demographics
NPI:1235831108
Name:DEL BOSQUE, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:DEL BOSQUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 RUBEN TORRES SR BLVD APT 4208
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-5236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1715 EXPRESSWAY 83 STE B
Practice Address - Street 2:
Practice Address - City:PENITAS
Practice Address - State:TX
Practice Address - Zip Code:78576-8335
Practice Address - Country:US
Practice Address - Phone:956-580-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist