Provider Demographics
NPI:1043245889
Name:LOWENTHAL, IVAN STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:STEPHEN
Last Name:LOWENTHAL
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 GOV CARLOS CAMACHO RD., STE B5
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3194
Mailing Address - Country:US
Mailing Address - Phone:671-647-4656
Mailing Address - Fax:671-647-4660
Practice Address - Street 1:633 GOV CARLOS CAMACHO RD., STE B5
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3194
Practice Address - Country:US
Practice Address - Phone:671-647-4656
Practice Address - Fax:671-647-4660
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT18789207RX0202X
GUM-1925207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001187897Medicaid
CT18789OtherCT. LICENSE
GUM-1925OtherGUAM LICENSE
06-1088532OtherTAX ID #
CT1683OtherCT CONTROLLED SUBSTANCE
CTCD0030Medicare PIN
CT001187897Medicaid
AL7584027OtherDEA
B84132Medicare UPIN
490000139Medicare ID - Type Unspecified