Provider Demographics
NPI:1457501827
Name:BUSTILLO CHAMS, IVAN JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:JOSE
Last Name:BUSTILLO CHAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-6002
Mailing Address - Country:US
Mailing Address - Phone:701-780-5000
Mailing Address - Fax:203-789-5184
Practice Address - Street 1:1000 SOUTH COLUMBIA ROAD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58206-6002
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:203-789-5184
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NDPT12924207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN719041Medicare UPIN