Basic Information
| Provider Information | |||||||||
| NPI: | 1619069846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAKUBA | ||||||||
| FirstName: | CHRYSOLOGUE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5401 OLD COURT RD | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | RANDALLSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211335103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106015524 | ||||||||
| FaxNumber: | 4106018946 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 RESERVOIR CIR | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | PIKESVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212086393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106531822 | ||||||||
| FaxNumber: | 4106531857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 11/28/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D15533 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | D15533 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 60061888 | 01 | MD | R/R MEDICARE PROVIDER # | OTHER | 030281300 | 05 | MD | MEDICAID |