Healthcare Provider Details

I. General information

NPI: 1609852490
Provider Name (Legal Business Name): HECTOR IVAN BURGOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 01/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 18 EAST PINE RIDGE HOSPITAL - INDIAN HEALTH SERVICE UNIT
PINE RIDGE SD
57770
US

IV. Provider business mailing address

PO BOX 1201 PINE RIDGE INDIAN HEALTH SERVICE UNIT
PINE RIDGE SD
57770-1201
US

V. Phone/Fax

Practice location:
  • Phone: 605-867-3273
  • Fax: 605-867-3271
Mailing address:
  • Phone: 605-867-3273
  • Fax: 605-867-3271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number9942
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: