Provider Demographics
NPI:1154311231
Name:CHIRIBOGA, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:CHIRIBOGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7503 SURRATTS ROAD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3395
Mailing Address - Country:US
Mailing Address - Phone:301-870-7001
Mailing Address - Fax:301-870-6697
Practice Address - Street 1:7503 SURRATTS ROAD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3395
Practice Address - Country:US
Practice Address - Phone:301-870-7001
Practice Address - Fax:301-870-6697
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0029896207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415527100 /377751100Medicaid
MD117772S95Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #
MD415527100 /377751100Medicaid