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General NPI Number Information
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NPI Number | 1619069846
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Entity Type | Individual
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Provider Name | CHRYSOLOGUE GAKUBA M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/28/2006
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Last Update Date | 11/28/2007
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Provider Practice Location Address
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Address Line | 2 RESERVOIR CIR SUITE 105
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City | PIKESVILLE
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State | MD
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Zip | 21208-6393
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Country | US
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Telephone | 410-653-1822
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Fax | 410-653-1857
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Provider Business Mailing Address
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Address Line | 5401 OLD COURT RD ATTN: CREDENTIALING
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City | RANDALLSTOWN
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State | MD
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Zip | 21133-5103
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Country | US
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Telephone | 410-601-5524
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Fax | 410-601-8946
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | D15533
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | D15533
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License Number State | MD
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