Provider Demographics
NPI:1154706588
Name:ILAKA-CHIBULUZO, SANDRA (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:ILAKA-CHIBULUZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:CHIBULUZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:133 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4312
Mailing Address - Country:US
Mailing Address - Phone:207-275-4201
Mailing Address - Fax:207-275-4262
Practice Address - Street 1:133 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4312
Practice Address - Country:US
Practice Address - Phone:917-330-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD241952080P0205X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology