Provider Demographics
NPI:1073588695
Name:MAMUYA, KOMSU F (MD)
Entity Type:Individual
Prefix:
First Name:KOMSU
Middle Name:F
Last Name:MAMUYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 SILAS DEANE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067
Mailing Address - Country:US
Mailing Address - Phone:860-258-3470
Mailing Address - Fax:860-571-6800
Practice Address - Street 1:1260 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-4362
Practice Address - Country:US
Practice Address - Phone:860-258-3477
Practice Address - Fax:860-571-6802
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT047922207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT047922OtherLICENSE
CTH01211Medicare UPIN