Provider Demographics
NPI:1508852914
Name:KOMEN, SUPOTE S (MD)
Entity Type:Individual
Prefix:DR
First Name:SUPOTE
Middle Name:S
Last Name:KOMEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1025 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:MONONGAHELA
Mailing Address - State:PA
Mailing Address - Zip Code:15063-1553
Mailing Address - Country:US
Mailing Address - Phone:724-258-8040
Mailing Address - Fax:724-258-2410
Practice Address - Street 1:1025 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:MONONGAHELA
Practice Address - State:PA
Practice Address - Zip Code:15063-1553
Practice Address - Country:US
Practice Address - Phone:724-258-8040
Practice Address - Fax:724-258-2410
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019272E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0691705Medicaid
PA0691705Medicaid
PAB35416Medicare UPIN