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General NPI Number Information
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NPI Number | 1457501827
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Entity Type | Individual
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Provider Name | IVAN JOSE BUSTILLO CHAMS MD
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Gender | Male
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Dates
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Enumeration Date | 09/23/2008
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Last Update Date | 01/29/2025
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Provider Practice Location Address
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Address Line | ALTRU CANCER CENTER 960 S. COLUMBIA ROAD
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City | GRAND FORKS
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State | ND
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Zip | 58201
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Country | US
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Telephone | 701-780-5400
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Fax | 203-789-5184
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Provider Business Mailing Address
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Address Line | PO BOX 13780
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City | GRAND FORKS
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State | ND
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Zip | 58208
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Country | US
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Telephone | 701-780-1891
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Fax | 203-789-5184
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | PT12924
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License Number State | ND
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