Healthcare Provider Details

I. General information

NPI: 1154706588
Provider Name (Legal Business Name): SANDRA ILAKA-CHIBULUZO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SANDRA CHIBULUZO M.D.

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 CORPORATE DR
BANGOR ME
04401-4312
US

IV. Provider business mailing address

133 CORPORATE DR
BANGOR ME
04401-4312
US

V. Phone/Fax

Practice location:
  • Phone: 917-330-7775
  • Fax:
Mailing address:
  • Phone: 207-275-4201
  • Fax: 207-275-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberMD24195
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: