Provider Demographics
NPI:1619069846
Name:GAKUBA, CHRYSOLOGUE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRYSOLOGUE
Middle Name:
Last Name:GAKUBA
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 1:5401 OLD COURT RD
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5103
Mailing Address - Country:US
Mailing Address - Phone:410-601-5524
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2 RESERVOIR CIR
Practice Address - Street 2:SUITE 105
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-6393
Practice Address - Country:US
Practice Address - Phone:410-653-1822
Practice Address - Fax:410-653-1857
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD15533207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD60061888OtherR/R MEDICARE PROVIDER #
MD030281300Medicaid
MD60061888OtherR/R MEDICARE PROVIDER #