Provider Demographics
NPI:1669443602
Name:DANG, KOMAL K (MD)
Entity Type:Individual
Prefix:DR
First Name:KOMAL
Middle Name:K
Last Name:DANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11202 OLD CARRIAGE RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ARM
Mailing Address - State:MD
Mailing Address - Zip Code:21057-9415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3455 WILKENS AVE
Practice Address - Street 2:L 10
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5213
Practice Address - Country:US
Practice Address - Phone:410-646-0555
Practice Address - Fax:410-644-4484
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-28
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD18362174400000X
MDD0018362261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD257951100Medicaid
MD257951100Medicaid
MDD72033Medicare UPIN