Provider Demographics
NPI:1508227356
Name:KOMAROVA, LADA (LAC)
Entity Type:Individual
Prefix:
First Name:LADA
Middle Name:
Last Name:KOMAROVA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 HOLLEY TER
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-2806
Mailing Address - Country:US
Mailing Address - Phone:516-313-1637
Mailing Address - Fax:
Practice Address - Street 1:9 W 31ST ST APT 20D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4548
Practice Address - Country:US
Practice Address - Phone:516-313-1637
Practice Address - Fax:201-496-6047
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001359171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist