Provider Demographics
NPI:1043772254
Name:PATEL, KOMAL
Entity Type:Individual
Prefix:
First Name:KOMAL
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 N. BROAD ST. RM. 001A
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4106
Mailing Address - Country:US
Mailing Address - Phone:215-926-9022
Mailing Address - Fax:
Practice Address - Street 1:1741 FRANKFORD AVE STE 100-A
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-2445
Practice Address - Country:US
Practice Address - Phone:215-425-2424
Practice Address - Fax:215-425-0342
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS022558207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program