Healthcare Provider Details

I. General information

NPI: 1043245889
Provider Name (Legal Business Name): IVAN STEPHEN LOWENTHAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 03/19/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 GOV CARLOS CAMACHO RD., STE B5
TAMUNING GU
96913-3194
US

IV. Provider business mailing address

633 GOV CARLOS CAMACHO RD., STE B5
TAMUNING GU
96913-3194
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-4656
  • Fax: 671-647-4660
Mailing address:
  • Phone: 671-647-4656
  • Fax: 671-647-4660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number18789
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberM-1925
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: