Provider Demographics
NPI:1477624658
Name:MADAN, KOMAL KAUR (BSC, OD)
Entity type:Individual
Prefix:MS
First Name:KOMAL
Middle Name:KAUR
Last Name:MADAN
Suffix:
Gender:F
Credentials:BSC, OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 GROVELAND AVE
Mailing Address - Street 2:APT 611
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3567
Mailing Address - Country:US
Mailing Address - Phone:503-789-4221
Mailing Address - Fax:
Practice Address - Street 1:317 GROVELAND AVE
Practice Address - Street 2:APT 611
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3567
Practice Address - Country:US
Practice Address - Phone:503-789-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3065152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist