=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407083744
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IAN J. CHAVES MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2009
-----------------------------------------------------
Last Update Date | 06/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9825 KENWOOD RD STE 105
-----------------------------------------------------
City | BLUE ASH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-6252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-872-4518
-----------------------------------------------------
Fax | 513-527-0416
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9825 KENWOOD RD STE 105
-----------------------------------------------------
City | BLUE ASH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45242-6252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-872-4518
-----------------------------------------------------
Fax | 513-527-0416
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 036137962
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 2014-00690
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 35133145
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------