Provider Demographics
NPI:1093775009
Name:KOMADA, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:KOMADA
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 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-5297
Mailing Address - Fax:
Practice Address - Street 1:1821 HILLANDALE RD
Practice Address - Street 2:SUITE 25C
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2659
Practice Address - Country:US
Practice Address - Phone:915-220-5510
Practice Address - Fax:919-220-6536
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600295207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8949870Medicaid
NC2027593Medicare PIN
NC2027593AMedicare PIN
G24135Medicare UPIN