Provider Demographics
NPI:1235616541
Name:KOMAL, UNKNOWN
Entity type:Individual
Prefix:
First Name:UNKNOWN
Middle Name:
Last Name:KOMAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:UNKNOWN
Other - Middle Name:
Other - Last Name:KOMAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7496
Mailing Address - Fax:
Practice Address - Street 1:2470 BLOOMINGDALE AVE STE 123
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-6403
Practice Address - Country:US
Practice Address - Phone:813-586-8530
Practice Address - Fax:813-605-6150
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11393600207RE0101X, 207R00000X
GA97885207RE0101X
FLME162750207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME162750OtherSTATE LICENSE NUMBER