Provider Demographics
NPI:1568598548
Name:THAKORE, KOMAL (OD)
Entity Type:Individual
Prefix:
First Name:KOMAL
Middle Name:
Last Name:THAKORE
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 1:30 CAMBRIDGEPARK DR
Mailing Address - Street 2:#3109
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2340
Mailing Address - Country:US
Mailing Address - Phone:617-864-7570
Mailing Address - Fax:
Practice Address - Street 1:1353 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-2932
Practice Address - Country:US
Practice Address - Phone:617-288-3230
Practice Address - Fax:617-288-4328
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4588152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA4588OtherMA OPTOMETRIST LICENSE
MA4588OtherMA OPTOMETRIST LICENSE