Provider Demographics
NPI:1144741562
Name:SHAH, KOMAL (OD)
Entity Type:Individual
Prefix:
First Name:KOMAL
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 TUXEDO PL
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-1011
Mailing Address - Country:US
Mailing Address - Phone:914-769-2288
Mailing Address - Fax:
Practice Address - Street 1:1144 AIRPORT BLVD STE 235
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-3106
Practice Address - Country:US
Practice Address - Phone:512-928-5808
Practice Address - Fax:512-928-5722
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008599152W00000X
TX9316TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist