Provider Demographics
NPI:1811284433
Name:VIAL, IVAN NICOLAS (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:NICOLAS
Last Name:VIAL
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 1:2450 NE MARY ROSE PL
Mailing Address - Street 2:STE 201
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 NE MARY ROSE PL STE 201
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7133
Practice Address - Country:US
Practice Address - Phone:541-317-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-03
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD180009208200000X
PAMT200491390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500719243Medicaid