Provider Demographics
NPI:1003296591
Name:TARIQ, KOMAL (MD)
Entity Type:Individual
Prefix:
First Name:KOMAL
Middle Name:
Last Name:TARIQ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 229
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45343-0229
Mailing Address - Country:US
Mailing Address - Phone:513-874-0486
Mailing Address - Fax:
Practice Address - Street 1:6730 ROOSEVELT AVE STE 303
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45005
Practice Address - Country:US
Practice Address - Phone:513-874-0486
Practice Address - Fax:513-280-8868
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.133073208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100557280Medicaid
OH0300858Medicaid