Healthcare Provider Details

I. General information

NPI: 1124253828
Provider Name (Legal Business Name): CAROL MICHELLE ILZARBE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2009
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 MOUNT AUBURN ST
CAMBRIDGE MA
02138-5502
US

IV. Provider business mailing address

26 HAWTHORN RD
MILTON MA
02186-1612
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-9970
  • Fax:
Mailing address:
  • Phone: 917-673-1602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number251823
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: