Provider Demographics
NPI:1831332741
Name:KOMLOS, JESSICA LEIGH (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LEIGH
Last Name:KOMLOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:LEIGH
Other - Last Name:CALDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:200 MEMORIAL AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5726
Mailing Address - Country:US
Mailing Address - Phone:410-871-7773
Mailing Address - Fax:
Practice Address - Street 1:200 MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5726
Practice Address - Country:US
Practice Address - Phone:410-871-7773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD73647208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD060123300Medicaid
MD248791Y64Medicare PIN