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
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Mailing Address - Street 1:PO BOX 13780
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58208
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:203-789-5184
Practice Address - Street 1:ALTRU CANCER CENTER
Practice Address - Street 2:960 S. COLUMBIA ROAD
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-780-5400
Practice Address - Fax:203-789-5184
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2025-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NDPT12924207RH0003X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN719041Medicare UPIN