Basic Information
| Provider Information | |||||||||
| NPI: | 1154311231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHIRIBOGA | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7503 SURRATTS ROAD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018707001 | ||||||||
| FaxNumber: | 3018706697 | ||||||||
| Practice Location | |||||||||
| Address1: | 7503 SURRATTS ROAD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018707001 | ||||||||
| FaxNumber: | 3018706697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 01/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | D0029896 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 415527100 /377751100 | 05 | MD | MEDICAID |