Provider Demographics
NPI:1861498792
Name:KOMRAD, MARK STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:KOMRAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:222 BOSLEY AVE
Mailing Address - Street 2:STE A3
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-4328
Mailing Address - Country:US
Mailing Address - Phone:410-494-4411
Mailing Address - Fax:410-510-1119
Practice Address - Street 1:222 BOSLEY AVE
Practice Address - Street 2:STE A3
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4328
Practice Address - Country:US
Practice Address - Phone:410-494-4411
Practice Address - Fax:410-510-1119
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD318182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4668MSMedicare ID - Type Unspecified
MDE17591Medicare UPIN