Provider Demographics
NPI:1063446144
Name:MBUYAMBA, MADELEINE (MD)
Entity Type:Individual
Prefix:
First Name:MADELEINE
Middle Name:
Last Name:MBUYAMBA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4342
Mailing Address - Country:US
Mailing Address - Phone:508-559-1567
Mailing Address - Fax:508-559-5073
Practice Address - Street 1:63 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4012
Practice Address - Country:US
Practice Address - Phone:508-559-6699
Practice Address - Fax:508-583-4649
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA159479208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
32530OtherHEALTHY START
MA98634901OtherNETWORK HEALTH
J25606OtherBLUE CROSS BLUE SHIELD
0017976OtherNEIGHBORHOOD HEALTH PLAN
32530OtherCHILDRENS MEDICAL SEC. PL
MA000000036884OtherBMC HEALTHNET
J25606OtherBLUE CROSS BLUE SHIELD
32530OtherHEALTHY START