Healthcare Provider Details

I. General information

NPI: 1457501827
Provider Name (Legal Business Name): IVAN JOSE BUSTILLO CHAMS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 01/29/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALTRU CANCER CENTER 960 S. COLUMBIA ROAD
GRAND FORKS ND
58201
US

IV. Provider business mailing address

PO BOX 13780
GRAND FORKS ND
58208
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-5400
  • Fax: 203-789-5184
Mailing address:
  • Phone: 701-780-1891
  • Fax: 203-789-5184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberPT12924
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: