Provider Demographics
NPI:1760902464
Name:IMTIAZ, KOMAL
Entity Type:Individual
Prefix:DR
First Name:KOMAL
Middle Name:
Last Name:IMTIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 N FLAMINGO RD # GME2
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1006
Mailing Address - Country:US
Mailing Address - Phone:734-219-2562
Mailing Address - Fax:
Practice Address - Street 1:703 N FLAMINGO RD # GME2
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1006
Practice Address - Country:US
Practice Address - Phone:734-219-2562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301112865207R00000X
MI5315086346207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine