Provider Demographics
NPI:1609852490
Name:BURGOS, HECTOR IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:HECTOR
Middle Name:IVAN
Last Name:BURGOS
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 1201
Mailing Address - Street 2:PINE RIDGE INDIAN HEALTH SERVICE UNIT
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-1201
Mailing Address - Country:US
Mailing Address - Phone:605-867-3273
Mailing Address - Fax:605-867-3271
Practice Address - Street 1:HIGHWAY 18 EAST
Practice Address - Street 2:PINE RIDGE HOSPITAL - INDIAN HEALTH SERVICE UNIT
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770
Practice Address - Country:US
Practice Address - Phone:605-867-3273
Practice Address - Fax:605-867-3271
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9942174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
82738Medicare ID - Type Unspecified
PRE62994Medicare UPIN